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Volume VII: 
Chemical Dependency 
and Diabetes 



Report of the 
Secretary's Task 
Force on 





Minority 
Health 




U.S. Department of Health and 
Human Services 



'i n 10 V1 1 01 



Volume VII: 
Chemical Dependency 
and Diabetes 



Report of the 
Secretary's Task 
Force on 



Black & 

Minority 

Health 



U.S. Department of Health and 
Human Services 

January 1986 



SECRETARY'S TASK FORCE ON BLACK AND MINORITY HEALTH 



MEMBERS 



Thomas E. Malone, Ph.D. , Chairperson 
Katrina W. Johnson, Ph.D., Study Director 



Wendy Baldwin, Ph.D 
Betty Lou Dotson, J.D. 
Manning Feinleib, M.D., 
William T. Friedewald, 
Robert Graham, M.D. 
M. Gene Handelsman 
Jane E. Henney, M.D. 
Donald R. Hopkins, M.D, 
Stephanie Lee-Miller 



Dr, 
M.D, 



P.H. 



Jaime Manzano 

J. Michael McGinnis , M.D. 

Mark Novitch, M.D. 

Clarice D. Reid, M.D. 

Everett R. Rhoades, M.D. 

William A. Robinson, M.D., M.P.H. 

James L. Scott 

Robert L. Trachtenberg 

T. Franklin Williams, M.D. 



ALTERNATES 



Shirley P. Bagley, M.S. 
Claudia Baquet, M.D., M. 
Howard M. Bennett 
Cheryl Daraberg, M.P.H. 
Mary Ann Danello, Ph.D. 
Jacob Feldman, Ph.D. 
Marilyn Gaston, M.D. 
George Hardy, M.D. 
John H. Kelso 



P.H. 



James A. Kissko 
Robert C. Kreuzburg, M.D. 
Barbara J. Lake 
Patricia L. Mackey, J.D. 
Delores Parron, Ph.D. 
Gerald H. Payne, M.D. 
Caroline I. Reuter 
Clay Simpson, Jr., Ph.D. 
Ronald J. Wylie 



TABLE OF CONTENTS 

Introduction to the Task Force Report v 

CHEMICAL DEPENDENCY 

Members of the Subcommittee on Chemical Dependency ix 

Report of the Subcommittee on Chemical Dependency 1 

Supporting papers commissioned by the Subcommittee 



1. Denise Herd, M.A. : A Review of Drinking Patterns and Alcohol 

Problems Among U.S. Blacks 77 



2. Raul Caetano, M.D. , Ph.D.: Patterns and Problems of Drinking 

Among U.S. Hispanics 143 



DIABETES 

Members of the Subcommittee on Diabetes 189 

Report of the Subcommittee on Diabetes 193 

Supporting papers commissioned by the Subcommittee 



1. John K. Davidson, M.D. , Ph.D.: The Effective Approach and 

Management of Diabetes in Black and Other Minority Groups .... 297 



2. Michael P. Stern, M.D.: Factors relating to the Increased 

Prevalence of Diabetes in Hispanic Americans 359 



INTRODUCTION TO THE TASK FORCE REPORT 
Background 

The Task Force on Black and Minority Health was established by 
Secretary of Health and Human Services Margaret M. Heckler in response 
to the striking differences in health status between many minority 
populations in the United States and the nonminority population. 

In January 1984, when Secretary Heckler released the annual report 
of the Nation's health, Health, United States, 1983 , she noted that the 
health and longevity of all Americans have continued to improve, but the 
prospects for living full and healthy lives were not shared equally by 
many minority Americans. Mrs. Heckler called attention to the longstanding 
and persistent burden of death, disease, and disability experienced by 
those of Black, Hispanic, Native American, and Asian/Pacific Islander 
heritage in the United States. Among the most striking differentials 
are the gap of more than 5 years in life expectancy between Blacks and 
Whites and the infant mortality rate, which for Blacks has continued to 
be twice that of Whites. While the differences are particularly evident 
for Blacks, a group for whom information is most accurate, they are 
clear for Hispanics, Native Americans, and some groups of Asian/Pacific 
Islanders as well. 

By creating a special Secretarial Task Force to investigate this 
grave health discrepancy and by establishing an Office of Minority Health 
to implement the recommendations of the Task Force, Secretary Heckler 
has taken significant measures toward developing a coordinated strategy 
to improve the health status of all minority groups. 

Dr. Thomas E. Malone, Deputy Director of the National Institutes of 
Health, was appointed to head the Task Force and 18 senior DHHS executives 
whose programs affect minority health were selected to serve as primary 
members of the Task Force. While many DHHS programs significantly benefit 
minority groups, the formation of this Task Force was unique in that it 
was the first time that attention was given to an integrated, comprehensive 
study of minority health concerns. 

Charge 

Secretary Heckler charged the Task Force with the following duties: 

• Study the current health status of Blacks, Hispanics, Native 
Americans, and Asian/Pacific Islanders. 

• Review their ability to gain access to and utilize the health 
care system. 

• Assess factors contributing to the long-term disparities in 
health status between the minority and nonminority populations. 



• Review existing DHHS research and service programs relative to 
minority health. 

• Recommend strategies to redirect Federal resources and programs to 
narrow the health differences between minorities and nonminorities. 

• Suggest strategies by which the public and private sectors can 
cooperate to bring about improvements in minority health. 

Approach 

After initial review of national data, the Task Force adopted a 
study approach based on the statistical technique of "excess deaths" 
to define the differences in minority health in relation to nonminority 
health. This method dramatically demonstrated the number of deaths among 
minorities that would not have occurred had mortality rates for minorities 
equalled those of nonminorities. The analysis of excess deaths revealed 
that six specific health areas accounted for more than 80 percent of the 
higher annual proportion of minority deaths. These areas are: 

• Cardiovascular and cerebrovascular diseases 

• Cancer 

• Chemical dependency 

• Diabetes 

• Homicide, suicide, and unintentional injuries 

• Infant mortality and low birthweight. 

Subcommittees were formed to explore why and to what extent these 
health differences occur and what DHHS can do to reduce the disparity. 
The subcommittees examined the most recent scientific data available 
in their specific areas and the physiological, cultural, and societal 
factors that might contribute to health problems in minority populations. 

The Task Force also investigated a number of issues that cut across 
specific health problem areas yet influence the overall health status of 
minority groups. Among those reviewed were demographic and social 
characteristics of Blacks, Hispanics, Native Americans, and Asian/Pacific 
Islanders; minority needs in health information and education; access to 
health care services by minorities; and an assessment of health professionals 
available to minority populations. Special analyses of mortality and 
morbidity data relevant to minority health also were developed for the 
use of Task Force. Reports on these issues appear in Volume II. 

Resources 

More than 40 scientific papers were commissioned to provide recent 
data and supplementary information to the Task Force and its subcommittees. 
Much material from the commissioned papers was incorporated into the 
subcommittee reports; others accompany the full text of the subcommittee 
reports. 



VI 



An inventory of DHHS program efforts in minority health was compiled 
by the Task Force. It includes descriptions of health care, prevention, 
and research programs sponsored by DHHS that affect minority populations. 
This is the first such compilation demonstrating the extensive efforts 
oriented toward minority health within DHHS. An index listing agencies 
and program titles appears in Volume I. Volume VIII contains more 
detailed program descriptions as well as telephone numbers of the offices 
responsible for the administration of these programs. 

To supplement its knowledge of minority health issues, the Task 
Force communicated with individuals and organizations outside the Federal 
System. Experts in special problem areas such as data analysis, nutrition, 
or intervention activities presented up-to-date information to the Task 
Force or the subcommittees. An Hispanic consultant group provided inform- 
ation on health issues affecting Hispanics. A summary of Hispanic health 
concerns appears in Volume VIII along with an annotated bibliography of 
selected Hispanic health issues. Papers developed by an Asian/Pacific 
Islander consultant group accompany the data development report appearing 
in Volume II. 

A nationwide survey of organizations and individuals concerned with 
minority health issues was conducted. The survey requested opinions 
about factors influencing health status of minorities , examples of success- 
ful programs and suggestions for ways DHHS might better address minority 
health needs. A summary of responses and a complete listing of the 
organizations participating in the survey is included in Volume VIII. 

Task Force Report 

Volume I, the Executive Summary, includes recommendations for 
department-wide activities to improve minority health status. The 
recommendations emphasize activities through which DHHS might redirect 
its resources toward narrowing the disparity between minorities and 
nonminorities and suggest opportunities for cooperation with nonfederal 
structures to bring about improvements in minority health. Volume I 
also contains summaries of the information and data compiled by the Task 
Force to account for the health status disparity. 

Volumes II through VIII contain the complete text of the reports 
prepared by subcommittees and working groups. They provide extensive 
background information and data analyses that support the findings and 
intervention strategies proposed by the subcommittees. The reports are 
excellent reviews of research and should be regarded as state-of-the-art 
knowledge on problem areas in minority health. Many of the papers commissioned 
by the Task Force subcommittees accompany the subcommittee report. They 
should be extremely useful to those who wish to become familiar in greater 
depth with selected aspects of the issues that the Task Force analyzed. 



vu 



The full 
Volume I : 
Volume II: 



Volume III: 
Volume IV: 
Volume V: 
Volume VI : 
Volume VII: 

Volume VIII: 



Task Force report consists of the following volumes: 

Executive Summary 

Crosscutting Issues in Minority Health: 

Perspectives on National Health Data for Minorities 
Minority and other Health Professionals Serving Minority 

Communities 
Minority Access to Health Care 
Health Education and Information 

Cancer 

Cardiovascular and Cerebrovascular Diseases 

Homicide, Suicide, and Unintentional Injuries 

Infant Mortality and Low Birthweight 

Chemical Dependency 
Diabetes 

Hispanic Health Issues 

Survey of Non-Federal Community 

Inventory of DHHS Program Efforts in Minority Health 



vm 



SUBCOMMITTEE ON CHEMICAL DEPENDENCY 



Mark Novitch, M.D. , Chairperson 
Formerly, Deputy Commissioner 
Food and Drug Administration 

Mary Ann Danello, Ph.D. , Acting Chairperson 
Special Assistant to the Commissioner for Science 
Food and Drug Administration 

Stuart L. Nightingale, M.D. 
Associate Commissioner 
Office of Health Affairs 
Food and Drug Administration 

Robert G. Niven, M.D. 

Director, National Institute on Alcohol and Alcohol Abuse 

Alcohol, Drug Abuse, and Mental Health Administration 

William Pollin, M.D. 

Director, National Institute on Drug Abuse 

Alcohol, Drug Abuse, and Mental Health Administration 

Everett Rhoades, M.D. 

Director, Indian Health Service 

Health Resources and Services Administration 

Robert Trachtenberg 

Deputy Administrator 

Alcohol, Drug Abuse, and Mental Health Administration 

Ronald J. Wylie 

Special Assistant to the Administator 

Health Care Financing Administration 

Staff Liaison: 

Frank Hamilton, M.D. , M.P.H. 



IX 






The Subcommittee gratefully acknowledges Gail Herzenberg of 
Technassociates Inc. and Brenda Hewitt, Special Assistant to 
the Director,. National Institute on Alcohol Abuse and Alcoholism, 
for their valuable assistance in preparing this report. 



REPORT OF THE 



SUBCOMMITTEE ON CHEMICAL DEPENDENCY 



I 



SUBCOMMITTEE ON CHEMICAL DEPENDENCY 
REPORT 



OVERVIEW 



This report reviews the role that chemical dependency plays in contributing 
to the health disparity between Blacks, Hispanics, Asians/Pacific 
Islanders, and Native Americans and the non-minority population. Based on 
excess mortality rates in minority populations due to cirrhosis, cancer, 
and unintentional injuries, the Subcommittee chose to include alcohol 
abuse, illicit drug abuse, and cigarette smoking as elements of chemical 
dependency. The Subcommittee chose not to include the abuse or misuse of 
licit drugs. Although these substances may contribute to the health 
disparity, few data are available on which to base an analysis. 

The impact of chemical dependency on the health of the general U.S. 
population is one of major proportion. The 1979 Surgeon General's Report, 
Healthy People , indicates that alcohol misuse is a factor in more than 10 
percent of all deaths and may be higher among minorities (1). The National 
Institute on Alcohol Abuse and Alcoholism has estimated that about one-half 
of all homicides in the United States are related to use of alcohol (2). 
An estimated 10 percent of homicides nationwide are associated with use of 
illegal drugs (3). In some of the nation's largest cities, the number of 
drug-related homicides is more than 20 percent (4). Tobacco use is a 
factor in more than 16 percent of all deaths, and nearly 90 percent of all 
lung cancers are caused by cigarette smoking (5). 

Data on the prevalence of chemical dependency for the minority population 
and the resultant impact are limited on health status. However, data on 
excess deaths among minorities due to cirrhosis, heart disease, 
unintentional injuries, homicide, and cancers of the mouth, larynx, tongue, 
esophagus, and lung provide an indication that chemical dependency has had 
a greater negative impact on the health of minorities. 

ALCOHOL 

Overview 

In focusing on the health-related risks for minorities as a result of the 
use/abuse of alcohol, it is important to note that alcohol as a subject of 
scientific inquiry is a relatively recent phenomenon. In 1969 a major 
United States Government publication noted that "available methods of 
research on alcoholism and excessive drinking have received virtually no 
significant support." (6) At the time of that report, except for 
anecdotal information regarding the prevalence of alcohol-related problems, 
national databases were virtually non-existent and research on these 
problems was minimal at best. 

Since 1969, the alcohol research field has made impressive gains in 
developing and enhancing the knowledge base with respect to the incidence 



and prevalence of alcohol-related problems, as well as many of the 
biological, psychological, social and economic factors involved in alcohol 
use and abuse. There remains a need to further refine the alcohol abuse 
and alcoholism database to assess the impact of alcohol use and related 
problems on minority as well as other sub-populations. For example, 
although the National Institute on Alcohol Abuse and Alcoholism has funded 
national surveys on alcohol use since 1971, these surveys were designed to 
elicit much-needed baseline data on the general population. As a result, 
minority samples from these surveys generally are too small to draw 
definitive statements and conclusions about alcohol use and the nature 
and/or extent of alcohol-related problems among the minority groups. 
Research focused on minorities has also suffered from inadequate sampling 
techniques, providing small and/or isolated samples from which information 
cannot be extrapolated to the entire minority group studies with any 
scientific credibility. 

The need for scientifically based data on which populations are at risk for 
what types of alcohol-related pathology is well-recognized as being crucial 
to the development of appropriate and effective prevention and treatment 
approaches. There is also emerging consensus among scientists and 
clinicians that alcoholism and related problems are coupled, and involve a 
wide range of medical, social, and legal problems which impact different 
populations at risk in different ways. These factors, among others such as 
growing maturity in the alcohol research field, have led epidemiological 
researchers to begin to design surveys with special sampling techniques to 
help develop a picture of alcohol use and abuse in sub-population groups, 
including minorities, and their risk for al cohol -rel ated problems. 
Additionally, several major national databases have recently become 
available from the National Center for Health Statistics and/or 
NIAAA-funded surveys which are expected to yield more comprehensive and 
statistically reliable information concerning alcohol use among minority 
groups. These national databases along with a number of regional datasets 
were highlighted at a national state-of-the-art conference. The 
Epidemiology of Alcohol Problems among U.S. Minority Groups, sponsored by 
NIAAA in September, 1985. This conference brought together researchers 
with expertise concerning U.S. minority groups and those who collect and 
analyze epidemiological data sets concerning alcohol use and abuse to 
discuss the most recent data on incidence and prevalence of alcohol 
problems among Black Americans, Hispanic Americans, American Indians, Asian 
Americans/Pacific Islanders. A set of proceedings will be published which 
will provide interested researchers with national and regional databases 
presented at the Conference, and an assessment of priority needs in future 
epidemiologic research concerning minorities. 

In addition to epidemiological research, basic research is also underway 
aimed at understanding some of the underlying biological mechanisms that 
could be a factor in the apparent differential risk for some 
alcohol-related problems among minorities. For example, sensitivity to the 
effects of alcohol varies greatly among individuals. There is evidence of 



a high prevalence of alcohol sensitivity among Asians or people of Asian 
decent which recent studies suggest may be based on genetic variation in 
the enzymes involved in alcohol metabolism. This difference may explain 
the apparently low risk for alcoholism in such persons and the low 
prevalence of alcohol problems in Asian populations. Further, research has 
also demonstrated differences in these enzymes among Blacks and Caucasian 
as well as Asians (7). It must be noted that these data at present are too 
preliminary to suggest more than the need for additional basic research 
(the discovery of a Black enzyme variant, for example, is based on a sample 
of biopsies from 23 liver specimens from Black Americans, of which 29 
percent were found to have a variant not yet seen in Caucasian liver 
specimens). They do, however, demonstrate the long-term investment which 
needs to be made to answer many of the questions concerning the health 
consequences of alcohol use and abuse on minority groups as addressed by 
this Task Force effort. 

MAGNITUDE OF THE PROBLEM 

Blacks 

Preval ence 



Since the 1950s, regular nationwide surveys of drinking patterns and 
problems have been conducted in the United States. Although these surveys 
cannot be assumed to be reliably representative of the Black population as 
a whole due to the small number and skewed geographical distribution of 
Black respondents, they do provide a general idea of Black drinking 
patterns over time. 

A 20 year-old national survey of drinking practices in the general 
population included 200 Black respondents (8). This survey showed that 
Black and White men varied little in their drinking patterns, but that 
Black women had a higher proportion than White of abstainers (51 percent 
vs. 39 percent) and of heavy drinkers (11 percent vs. 7 percent). Two 
followup studies of still smaller numbers of "problem drinkers" in the 
Black group indicated that Blacks had a higher rate of "social -consequence 
drinking problems (9, 10). However, further analysis of these data 
suggested that high problem rates among Blacks may be more related to their 
poverty, urban residence and youthfulness than racial identity. A 1979 
survey of American drinking practices found contrasting results to the 
earlier national survey. It found that both Black men and Black women were 
more likely to classify themselves as "abstainers" (30 percent and 49 
percent respectively) than White men and women (25 percent and 39 percent 
respectively). Moreover, White men had a 50 percent higher rate (21 
percent vs. 14 percent) of heavier drinking than Black men while White 
women had lower rates of heavier consumption than their Black counterparts 
(4 percent vs. 7 percent). White men in this survey were twice as likely 
as Black men to exhibit social problems as a result of drinking (6 percent 
3 percent) although White women and Black women on this measure were 



vs 



quite similar (3 percent vs. 2 percent). Among Blacks of both sexes who 
reported drinking, however, the proportion of heavier drinkers and of 
drinkers with alcohol-related problems were similar to the proportions for 
most other groups (11). According to a recent study, when rates of 
excessive drinking and rates of self-reported drinking problems are 
examined for the Black population, no consistent pattern of high alcohol 
consumption or high problem rates emerge for the groups as a whole. Black 
drinking patterns appear heterogeneous and differ along lines similar to 
patterns reported in the general American population. Rates of drinking 
vary greatly by geographical region, sex, and religious background (12). 
While many questions remain to be answered with respect to drinking 
practices and the prevalence of alcohol-related problems among Blacks, 
reliable data have been reported for some biomedical consequences. Perhaps 
the most compelling of these consequences is cirrhosis of the liver, where 
Black cirrhosis death rates appear to be significantly higher than White. 

According to a paper commissioned by the Department of Health and Human 
Services for the Task Force on Black and Minority Health, mortality rates 
based on data from death certificates and population data collected by the 
U.S. Census indicate that for all ages, the non-White cirrhosis mortality 
figures are twice as high as for Whites.* Further, although deaths from 
cirrhosis have been consistently greater for males than for females, 
regardless of race, the most dramatic change in cirrhosis mortality since 
1950 occurred among non-White males, whose rate increased fourfold between 
1950 and 1973 (14). Mortality from liver cirrhosis has consistently 
declined among all race-sex groups in this country since 1973, with rates 
appearing to have stabilized since 1979, although rates among non-White 
males remain substantially higher than levels of the three other race-sex 
groups (15). In 1979, age-adjusted death rates for non-Whites were 21.1 
per 100,000 population as compared to 11.1 per 100,000 persons for Whites 
(16). There are some encouraging reports in recent literature of a decline 
in cirrhosis deaths in White and non-White populations, lending cautious 
optimism that this trend will continue. 

Other medical problems for which Blacks may be at disproportionate risk as 
a result of alcohol include esophageal cancer and hypertension. National 



* The non-White classification is used by the U.S. Census to designate 
racial groups other than Caucasians in U.S. mortality reports and 
population tables. The non-White rates provide a rough estimation of 
Black cirrhosis mortality since Blacks accounted for about 92 percent of 
the U.S. non-White population during most of the years covered in this 
analysis. (13) 



Cancer Institute data show that between 1979-1981, Black males in the 35-44 
age group had an esophageal cancer incidence rate 10 times that of Whites 
(18). Further, according to one researcher, trends in mortality due to 
cancer of the esophagus share many similarities with the patterns observed 
in cirrhosis rates, with recent case control studies arguing that alcohol 
consumption may be a primary etiological agent in developing this tumor 
among Blacks (19). Hypertension is of concern in that Blacks suffer from a 
significantly higher rate of hypertension than other groups. This already 
high rate can be further complicated by excessive use of alcohol (20). 

There are references, although minimal, in the literature to the higher 
prevalence of Fetal Alcohol Syndrome/Fetal Alcohol Effects (FAS/FAE) among 
children of Black women who drink. The data, however, are inconclusive at 
best. Although the significantly higher abstention rates for Black women 
as compared to White women have been substantiated through a number of 
surveys, as previously noted, survey data suggest the greater frequency of 
heavier drinking among Black women than among I'/hite women (7 percent vs. 4 
percent). Because FAS/FAE have been positively associated with heavy use 
of alcohol, these data would tend to suggest that the prevalence of FAS/FAE 
in the Black population may be higher than in the White population. Given 
the demonstrated differences in infant mortality rates between the Black 
and White populations, and the relationship between alcohol use and adverse 
pregnancy outcome, it is clear that this area needs more extensive 
investigation. 

In terms of Black youth, national surveys have consistently supported the 
contention that Black youths drink less than White youths, have 
consistently higher abstention rates and consistently lower rates of 
heavy drinking and alcohol-related social consequences than their White 
counterparts (21). A 1977 review of the literature from 1960-1975 reported 
that most surveys of Black youth showed that they were less likely to use 
alcohol or to exhibit problems related to drinking than White youth (22). 
This was further confirmed in a 1978 national survey of adolescent drinking 
practices in which Black 10th-12th graders reported higher rates of 
abstention that White 10th-12th graders (36.1 percent vs. 21.1 percent) and 
lower heavier drinking rates (3.9 percent vs. 12.1 percent) (23). While 
these are positive revelations, it should be noted that Black males appear 
to begin to report high rates of heavy drinking and social problems due to 
drinking after the age of 30 compared to White males where heavy and 
problem drinking is concentrated in the 18-25 years-olds. This pattern of 
late onset drinking, if it leads to prolonged, heavy consumption, may put 
Black males at greater risk for chronic diseases related to alcohol 
consumption (24). 

Treatment 



Most of what is know about treatment for alcohol abuse and alcoholism among 
Black Americans is based on the observations of health care professionals 
involved in providing services to Black clients. According to the director 



of a large alcohol and drug abuse treatment program serving a primarily 
urban Black community, Black individuals and families tend to seek help for 
alcohol problems later in the progression of the illness than their White 
counterparts. As a consequence, Black families are significantly more 
dysfunctional and resistant to messages of recovery than comparable White 
families (25). Another author on alcohol and Blacks noted that the problem 
of alcoholism has not yet been recognized and accepted in the Black 
community so as to allow for coimnunity-de fined standards, folkways, and 
mores on the subject of drinking. Studies are needed in all areas of 
alcohol abuse among Black Americans — psychological, cultural, biological, 
and socioeconomic (26). 

Hispanics 

Prevalence 

Studies of "Hispanic" drinking practices and consequences are, if anything, 
even more seriously lacking than those of Blacks. Until 1976, most common 
measures of alcohol-related problems (mortaility, arrests, and treatment) 
did not provide a Hispanic category. Additionally, most surveys and other 
types of research have not been designed specifically to address the 
heterogeneity of the Hispanic American popultion which is made up of quite 
different sub-cultural groups with cultural drinking practices which may be 
markedly different. Samples of Hispanic Americans in national surveys also 
are generally too small to make any but the most general statements about 
Hispanic patterns of use and abuse of alcohol. Nonetheless, there is some 
indication that Hispanics, particularly young males, suffer dispropor- 
tionate health consequences as a result of their use of alcohol. 

Self-reports of drinking patterns in a 1979 national survey suggests that 
Hispanic groups of both sexes, but especially males, have relatively high 
levels of heavier drinking and of problems associated with drinking (27). 
It should be noted, however, that the samples of Hispanics in this survey 
were too few to arrive at "statistically meaningful conclusions." Hence, 
only glimpses of drinking patterns in certain subgroups are offered. These 
data contrast with the findings from some regional surveys which show 
marked differences in the drinking practices and problems of Hispanic males 
and females. A statewide survey done in California, for example, showed a 
striking difference in the Chicano population between men and women, with 
far fewer women classified as frequent, heavy drinkers (3 percent) than men 
(13 percent) (28). With respect to the drinking patters of Hispanic women, 
a survey which consisted of a series of representative samples of the 
population in the San Francisco Bay Area between 1977 and 1980 found that 
Hispanics as well as Black women exhibited much higher abstention rates (32 
percent, 29 percent respectively) than White women (18 percent). Hispanic 
women also had lower heavy drinking rates (3 percent) than both Black women 
(6 percent) and White women (4 percent) (29). 



Mortality statistics for the United States do not separately identify 
Hispanics and information from regional surveys is not only limited but 
cannot be generalized to provide a national picture of alcohol-related 
deaths among Hispanic Americans (30). Several studies, however, suggest 
that death rates from cirrhosis of the liver among Hispanic Americans may 
be higher than for the general population. These results have been 
reported for Mexican-Americans, and Puerto Ricans (31). In terms of 
overall mortality, one local study done in Southern California reported a 
sharp rise from approximately 4 to 18 percent in the proportion of 
alcohol-related deaths among Mexican-Americans autopsied in a Southern 
California University Medical Center between 1950 and 1970, although 
alcohol-related was not defined. For 1970, the results published in this 
study indicated that 52 percent of all autopsies performed at the Medical 
Center on Mexican-American men between the ages of 30 and 60 were alcohol- 
related compared with 24 percent for White men, 23 percent for White women, 
22 percent for Black men, 21 percent for Black women, and 20 percent for 
Mexican-American women. Another study using autopsy data from this Medical 
Center from 1970-1976, however, showed a decline in the proportion of 
Hispanic male alcohol-related deaths declined to 26 percent, and female 
Hispanic alcohol-related deaths declined to 7 percent (32). These studies, 
however, were undertaken by different investigators; their methodology may 
not be comparable and the results in terms of indicating a trend should be 
viewed with caution. 

Studies have also reported higher arrests rates for public drunkenness and 
for drunk driving among Hispanic Americans than for the general population 
which may increase the risk for al cohol -related accidents and death in this 
population. 

While there is some indication that Hispanics are overrepresented among 
those dying of alcohol-related causes, these data stem mainly from studies 
in a few cities or countries located mainly in the Southwest. Little is 
known about the health consequences of alcohol use in the rest of the 
country. Further, although statistics on public drunkenness and drunk 
driving show a disproportionate number of Hispanics, it is uncertain 
whether this is as a result of more drunkenness or of more police 
surveillance in Hispanic neighborhoods (33). 

Alcohol use and abuse among Hispanic youth have also been studied, although 
the data at this point are inconclusive. A self-reported sample of 
Hispanic American youth in a 1978 National survey on adolescent drinking 
had a lower percentage of heavier drinkers (4.2 percent) than the White 
youths samples (12.2 percent). However, in this survey, the percentage of 
Hispanic youths who reported abstaining from alcohol was equal to that of 
the White students (21 percent) (34). It should be noted that the sample 
of Hispanic youth (10th-12th graders) was far too small (n=264; total 
sample, n=4,198) to make any but the most general interpretations. 
Contrasts in reported data of alcohol use among Hispanic college students 
also is also inconclusive. A 1973 study on alcohol use among college 



students found that White students had higher rates of alcohol use than 
Blacks, Asian Americans, or Hispanic Americans. Another study done in 1979 
found that Puerto Rican adolescents had lower overall alcohol consumption 
rates than American adolescents. However, a 1976 study found a 
predominantly Hispanic American sample of secondary school students 
reported using alcohol as often as the predominantly White student group 
(35). According to the author of a report on patterns and problems of 
drinking among U.S. Hispanics commissioned by the Secretary's Task Force, 
drinking rates among Hispanic male age cohorts varies, with the rate of 
heavy drinking dropping continuously with age so that the percentage of 
frequent heavier drinkers among younger men is almost four times higher 
than among those 50-59 years of age (36). The author concludes that 
targeting prevention efforts on the group most severely affected — youth 
and young adult males — should be a primary feature of any prevention 
strategy. 

American Indians/Alaskan Natives 

Preval ence 

Alcohol use varies tremendously from one tribe to the next — some tribes 
have fewer drinking adults than the U.S. population (30 percent compared to 
67 percent for the U.S.) while other tribes have more drinkers (69-80 
percent) (37). The prevalence of alcohol-related problems are also highly 
variable. Of the top ten causes of death among American Indians, five are 
directly related to the use of alcohol. Clearly, the health consequences 
of alcohol use and abuse for American Indians is a major public health 
concern which must be addressed. 

A recent report based on age adjusted mortality rates found that the 
mortality rate from alcohol-related causes of death was more than three 
times higher among Native Americans than among other groups. The Indian 
Health Service lists five of the top ten causes of death among Indians as 
being directly related to alcohol — accidents, cirrhosis of the liver, 
alcoholism, suicide and homicide. These five categories account for 35 
percent of all deaths among the American Indian people (38). 

Accidents are the number one cause of death within the American Indian 
population and account for an estimated 21 percent of all deaths. The 
Indian Health Service estimates that 75 percent of all accidental deaths 
among Indians are alcohol-related (39). 

The fourth ranked cause of death among Indians is cirrhosis of the liver, 
accounting for nearly 6 percent of the total death within this group, 
compared with 1.7 percent of the total deaths for the Nation as a whole. 
According to one study, the cirrhosis mortality rates for American Indians 
are higher than rates for Blacks or Whites at every age level, and the 
highest rates for Indians occur at younger ages. By examining the 
sex-specific data separately, this study also shows that Indian women have 



much higher cirrhosis mortality rates than either Black or White women at 
all age levels (40). 

The diagnosis of alcoholism accounts for an estimated 3.2 percent of all 
Indian deaths, which is approximately four times the rate for the nation as 
a whole. Researchers suggest that the ranking of this diagnosis might be 
even higher if all deaths from alcoholism were reported accurately. A 
study of alcohol-related morbidity and mortality among Oklahoma Native 
Americans reported the total Indian death rate from alcoholism between 1974 
and 1976 as 59.8 per 100,000 population, compared with 8.6 per 100,000 for 
the total population (41). 

Suicide accounts for 2.9 percent of all deaths within the American Indian 
population, or twice the national percentage. It is estimated that 80 
percent of all deaths by suicide within the Indian community are 
alcohol-related (42). 

The 10th ranked cause of death in American Indian communities is homicide, 
which accounts for an estimated 2 percent of total deaths. The Indian 
Health Service reports that 90 percent of homicides committed within Indian 
communities occur while either the perpetrator or the victim or both are 
under the influence of alcohol (43). 

According to one paper commissioned by the National Institutes on Alcohol 
Abuse and Alcoholism for the Navajo tribe, the largest tribe in the United 
States, the average life expectancy of a Navajo male (58.8) years could be 
increased a full 6.2 years by the elimination of motor vehicle accidents 
and cirrhosis of the liver alone (44). 

Another medical consequence of alcohol abuse for which Native Americans 
appear to be at risk is Fetal Alcohol Syndrome/Fetal Alcohol Effects 
(FAS/FAE), although the risks appear variable depending upon the 
sub-population group. An epidemiological study of FAS among American 
Indians of the southwest concluded that the incidence and patterns of 
recurrence of FAS among the three groups studied (Plains Indians, Navajo, 
and Pueblo) showed consistent differences ranging from a high of 10.3 per 
1,000 live births for Plains Indians, to 1.3 per 1,000 live births in the 
Navajo population. The authors conclude that these differences were of 
greater magnitude than had been expected and could best be explained by the 
unique social and cultural dynamics of each of the three populations 
studied. The study also showed that 25 percent of all mothers who had 
produced one FAS child had also produced others. From a prevention 
standpoint, the authors of this study note that the ability to define 
sub-populations at risk is an important public health issue in terms of 
designing education and other measures targeted at women of childbearing 
years (45). 



Treatment 

According to one study, an extensive evaluation of nine Indian alcoholism 
programs for Navajos (the largest U.S. Native American tribe) in 1979 
documented the major problems common to many Indian alcoholism projects. 
These programs were found to have inadequate funding, extremely poor pay 
and no career ladder for counselors and other employees; counselors with 
little or no professional training; counseling generally limited to the 
individual, adult clients with little emphasis on family and community; 
isolation from professional and community input, neglect of the Indian 
spiritual aspects of life; little followup; lack of diversified staff and 
treatment modalities; and no guiding theoretical or ideological 
perspective. According to the author, 73 percent of all Indian community 
leaders in the survey rated the programs as "inadequate" and many 
specifically mentioned a lack of outreach and youth services. However, the 
author concludes, even if existing Indian alcohol treatment programs were 
to improve dramatically, "their particular problem oriented, client 
centered approach would not be adequate to solve this major public health 
problem." Three types of programs were described which need to be 
developed and implemented: the reduction of the adverse medical 
consequences of alcohol and drug abuse which would seek to apply a public 
health or primary prevention approach to minimize alcohol-related morbidity 
and mortality among Indians; community based preventive education for 
reducing alcohol and drug abuse in the future; and multi-faceted 
rehabilitation for chronic abusers with therapies tailored to the needs of 
the particular individual. At the very least, such treatment should be 
able to accommodate people in need of a modern or traditional treatment 
track (46). 

Alaskan Natives 



Prevalence 

With respect to Alaskan Natives, available data suggests that a wide 
variety of factors affect the drinking practices of Native Alaskans 
including climate, daylight hours, the forceful introduction of modern 
technology (post World War II) and dramatic urbanization, with new leisure 
time that replaced a subsistence way of life. Alcoholism and 
alcohol-related problems can be considered the number one health problem. 
One study states that Alaskan Natives (who comprise only 17 percent of the 
State) account for 60 percent of the deaths due to alcoholism; 67 percent 
of all client admissions to State-funded alcoholism programs; and 25 
percent of the deaths due to cirrhosis of the liver. This same study cites 
43 percent of all suicides; 38 percent of all homicides; 42 percent of all 
homicide arrests; 44 percent of all aggravated assault arrests; and 31 
percent of arrests for forcible rape associated with the Alaskan Native 
population (47). While it cannot be said with certainty that alcohol is 
the cause of these violent episodes, the relatedness of alcohol to many 
acts of violence is generally accepted. 



10 



Asian Americans/Pacific Islanders 



Prevalence 



Asian Americans remain one of the less visible populations in the United 
States, a fact influenced by several factors; their comparatively small 
numbers, their geographic distribution, housing patterns and culturally 
derived lifestyle which historically has involved reliance on family and 
community rather than social or other service agencies. As a result, much 
of what is thought about Asian Americans borders on the stereotypical, 
especially regarding alcohol use and abuse (48). It should be noted, 
however, that there are over 20 nationalities covered by the term Asian 
American, and there are wide variations in drinking between and among these 
subgroups. 

Research on the enzymes involved in alcohol metabolism have shown that some 
individuals, particularly persons of Oriental derivation, metabolize 
alcohol much more quickly than do non-Orientals, It is estimated that some 
50 percent of Asian populations even at moderate alcohol intake, experience 
an "alcohol flush reaction," a systemic reaction consisting of facial 
flushing and rapid heart rate and, in severe cases, nausea, vomiting and 
low blood pressure (49). It has been hypothesized that this flushing 
reaction may provide some protection against heavy drinking and related 
problems, however, some researchers and clinicians believe that alcohol 
problems including medical consequences of alcohol use such as cirrhosis, 
may exist in spite of this. The relationship between this sensitivity and 
the use of alcohol and the incidence and prevalence of alcohol problems 
among the Asian American population needs further examination and 
clarification. 

The very limited data available on alcohol-related consequences among Asian 
Americans shows that in general, both Chinese and Japanese Americans have 
minimal arrest records (according to FBI statistics). If arrested, 
however, individuals from these two groups are most likely to be charged 
with an alcohol-related violation, such as driving under the influence or 
drunkenness. These alcohol-related offenses accounted for 27.8 percent of 
Japanese American arrests in 1978 and 13.1 percent of Chinese American 
arrest rates. By contrast, the White arrest record for alcohol-related 
offenses in this same year was 31.9 percent. Blacks, 14.6 percent, and 
American Indians, 47.2 percent (50). 

Native Hawaiians 



Prevalence 

Native Hawaiians are a minority group often overlooked in survey data and 
reports on minority group problems in the U.S. However, there is some 
evidence to suggest that Native Hawaiians' appear to be at greater risk 
than all other ethnic groups in Hawaii, including Caucasians, for death 
from alcohol-related motor vehicle accidents. Based on available data. 
Native Hawaiians also appear more likely to report heavier drinking than 
other Hawaiian population groups. 



11 



A 1979 report on Mental Health and Substance Abuse Among the Native 
Hawaiian population included state-wide statistics to compare Native 
Hawaiians with all other groups in the state. (The other groups were not 
further broken down into ethnic/racial categories.) In this study, Native 
Hawaiians appear to be arrested for driving while intoxicated with less 
frequency than would be predicted on the basis of their numbers in the 
Hawaiian population (256.7 per 1,000 population vs. 449.5 per 100,000 
population for all other groups), however, they appear to be at somewhat 
greater than expected risk for involvement as drivers in fatal motor 
vehicle accidents due to intoxication (15.3 per 100,000 population vs. 13.9 
per 100,000 population for all other groups). In this same study. Native 
Hawaiians were also more likely to report heavier drinking, i.e., 12 or 
more drinks per week, than all other groups in the Hawaiian population 
(30.5 percent for Native Hawaiians vs. 18 percent for all other groups). 
(51) 

CONCLUSIONS AND FUTURE DIRECTIONS 

It is clear from the above discussion that alcohol contributes 
significantly to the health disparity which exists between persons from 
minority groups and those from the non-minority population. It is equally 
clear, however, that minority group status alone is not a factor in the 
health disparity, and all persons of a particular minority group are not at 
equal risk for alcohol-related adverse health consequences. The need for 
culturally-appropriate prevention and treatment programs is acknowledged, 
as well as the clearer need for the continuing support of research. 



12 



DRUG ABUSE 

Overview 

During the late 1960 's and 1970 's drug abuse reached alarming proportions 
across most racial groups. Although the projected size of the adolescent 
and young adult population in the 1980's and 1990's will decrease, and drug 
use generally is inversely proportional to age (52), preliminary data 
suggest that the intensity and impact of drug abuse among minority 
populations is of significant proportion and will not necessarily diminish. 
These data suggest that certain minority populations may suffer certain 
adverse consequences of drug abuse disproportionately to their 
representation in the population. 

In the past, national surveys of drug and alcohol abuse were designed to 
focus on the general population. Consequently, there are no national data 

on race or ethnic specific rates for drug abuse or the health consequences 
of drug abuse. 

Estimates of the prevalence of drug abuse obtained from household surveys 
must be viewed conservatively, since certain potentially high risk 
subgroups are not included in the sample. These would include, for 
example, persons with no fixed residence, prison inmates, and students 
living in college dormitories. In addition, there is a scarcity of direct 
measures of drug abuse prevalence; consequently the use of secondary or 
implied measures of prevalence is necessary. Data on admissions to treat- 
ment centers, emergency room cases, and medical examiner cases among 
minorities can be viewed as secondary indicators of prevalence and can 
indicate to a degree the extent and consequence of drug abuse among 
minority populations. 

Another problem in obtaining data on minorities is that Blacks, Hispanics, 
Native Americans, and Asian Americans are sampled proportionately to their 
numbers in the general population. The actual sample size for minorities 
is substantially smaller than that for Whites (i.e., 1,093 minorities were 
sampled in the 1982 National Household Survey on Drug Abuse (NHSDA) as 
compared to 4,520 Whites). Thus, estimates for minorities are subject to 
larger sampling errors than are estimates for Whites and estimates cannot 
be made for separate race/ethnic groups. The 1985 NHSDA is oversampling 
Blacks and Hispanics in an effort to provide more reliable estimates of 
drug abuse prevalence in minority populations. 

Data from the 1982 NHSDA indicate that the prevalence of reported drug use 
within the household population is generally higher in urban areas than in 
suburban or rural areas (53). Therefore, to the extent that minorities are 
more likely to reside in inner city areas, they may be at greater risk of 
drug abuse and ultimately the negative social and health consequences 
associated with drug abuse. 



13 



The overall prevalence of drug abuse in the general household population, 
ages 12 and older, is about the same for minorities as it is for Whites. 
Data from the 1982 NHSDA showed that about one-third (32 percent) of Whites 
and minorities had used drugs illicitly at some time in their lives (54). 
This would include having at least tried an illicit drug, such as 
marijuana, heroin, hallucinogens or cocaine, or having used a prescription 
psychotherapeutic drug, such as tranquilizers, sedatives, stimulants or 
analgesics, for nonmedical reasons. Similar levels of current illicit use 
(use during the month prior to interview) were also reported by both groups 
(12 percent of Whites and 13 percent of minorities). 

It is interesting to note that while Whites and minorities in the general 
household population experience about the same overall levels of drug 
abuse, minorities were more likely than Whites to report marijuana as their 
only form of illicit drug use. For example, the 13 percent current illicit 
drug use cited above for minorities was comprised of 10 percent reporting 
marijuana only and 3 percent reporting other drugs with or without 
marijuana use. The corresponding figures for Whites were 7 percent and 5 
percent, respectively. 

Among both minorities and Whites, the highest levels of current drug use 
were reported by young adult males, 18-25 years old. Thirty-six percent of 
young adult minority men reported current use of marijuana only; an 
additional five percent reported use of other drugs (with or without 
marijuana use). Among young adult White men, 21 percent reported current 
use of marijuana only, and 18 percent reported use of other drugs (55). 

Another important aspect of marijuana use is that unlike the pattern for 
young adult Whites, a decreasing trend in use has not been observed among 
young minority adults, ages 18-25. A decreasing trend of marijuana use 
also has been noted among White youths, ages 12-17, and this trend does 
appear to be paralleled by a decreasing trend among minority youths in that 
same age group (56). The marijuana trend data are shown in Table 1. 

The use of heroin, even though included in the general household population 
questionnaire, cannot be measured adequately in household surveys both 
because it is a relatively rare event and because it is more likely to 
involve the nonsampled population subgroups and also more likely to be 
underreported. This is a particularly important consideration in any 
assessment of drug abuse problems among minorities since the data available 
from hospital emergency rooms and from drug abuse treatment programs 
indicate that heroin use is a more serious problem among Blacks and 
Hispanics than among Whites. (See the discussion of these data under the 
minority specific sections of this report.) 

The 1982 National Drug and Alcoholism Treatment Utilization Survey (NDATUS) 
is a national survey of all known existing public and private treatment 
units. When used in conjunction with 1980 census data, information from 



14 



this survey on clients, ages 15-64, provide race- and ethnic-specific rates 
for clients in treatment. The survey data indicates that the number of 
minority clients in treatment in the Nation per 100,000 population is 
greater than it is for Whites (57). (See the discussion of the data under 
the minority specific section of this report.) 

There are many potential negative health consequences of drug abuse. To 
the extent that some minorities are more involved proportionately in drug 
abuse the health consequences are greater. Some of the negative 
consequences include fatal and nonfatal overdose, hepatitis B infection. 
Acquired Immune Deficiency Syndrome (AIDS) and bacterial endocarditis. 
Drug abuse may increase the risk of homicides and crime, accidents and 
injuries, Parkinson's disease, low birth weight, and suicide and 
psychiatric problems. 

In addition, drug abuse may have negative effects on employment, school 
achievement, socioeconomic status, and family stability, although it is 
difficult to determine if these factors are causes or effects of drug 
abuse. The associations between drug abuse and many of these negative 
consequences are based primarily on case studies or case reports. There 
are few known methodologically sound epidemiological case-control or 
prospective studies that have been done in either White or nonWhite 
populations. 

Intravenous drug use appears to increase the risk of potentially fatal 
infections from hepatitis B, AIDS, and bacterial endocarditis. A 1984 
national surveillance of AIDS has determined that 17.2 percent of AIDS 
patients were intravenous drug users (58). However, no breakdown by race 
was provided for the abusers. 

There are also several small studies which indicate that the incidence of 
fatal infections from Hepatitis B (59) and bacterial endocarditis (60) is 
associated with intravenous drug administration, while some of these 
studies included race/ethnicity. The limited data does not support the 
conclusion that race, independent of pareuteral drug abuse is a risk factor 
for these conditions. 

Data from the CI iented Oriented Data Acquisition Process (CODAP) indicate 
that certain minorities are more likely to report intravenous use than 
Whites (61). To the extent that minorities are more involved in the 
intravenous use of drugs, they are at increased risk for multiple negative 
health consequences. Health consequences studies which report data with 
racial and ethnic identifiers are discussed in the minority specific 
sections of this report. 



15 



MAGNITUDE OF THE PROBLEM 

Blacks 

Data from the 1980 census indicate that Blacks constitute 11.7 percent of 
our population, however, they constitute 22,5 percent of the population of 
the inner cities (62). As such, they may be at greater risk of drug abuse 
and its consequences. 

Evidence of higher rates of drug use in populations having no fixed 
residence is provided by a 1983 study of drug use among tenants of single 
room occupancy hotels (S.R.O.) in New York City (63). Results suggest that 
Blacks have higher rates of drug use than Whites for marijuana, cocaine, 
heroin, and illicit methadone. This is important since Blacks and 
Hispanics constitute 67 percent of the S.R.O. population compared to 40 
percent of the household population in New York City. Further analysis of 
a sample of Blacks matched for age and sex from the household population 
and the S.R.O. population indicated that the Black S.R.O. tenants were 
three times as likely to have used drugs recently as were the Black New 
York City household residents (63). 

Data obtained from the 1982 National Drug and Alcoholism Treatment 
Utilization Survey (NDATUS), a national survey of public and private 
treatment units, suggest that Blacks are three times more likely to be in 
treatment for drug abuse-related problems than are Whites (64). 

Through 1981, treatment data were collected nationally through the Client 
Oriented Data Acquisition Process (CODAP). Since 1982, States have 
submitted data on a voluntary basis. In the past, the data have been 
criticized as biased since they represent primarily clients admitted to 
publicly-funded programs. Even if the overall distributions of admissions 
by race did differ from admissions to privately-funded programs, it is 
however, legitimate to examine the distributions within race/ethnic 
categories . 

The following discussion will focus on treatment data submitted by 23 
States, Puerto Rico, Washington, D.C., Guam, and the Virgin Islands during 
part or all of the year of 1983. In looking at these data it is important 
to know that California accounted for approximately 46 percent of the 
admission data. Of the 182,002 clients admitted to treatment in 1983, over 
half were White and 23.4 percent were Black. 

Black clients were more likely than White clients to report a primary 
problem with heroin, cocaine, and PCP. Black clients were also more likely 
to report "other" drugs than White clients. 

Black clients were likely to be older than White, Hispanic, or American 
Indian clients at admission for each of the four drugs — heroin, cocaine, 
marijuana, and PCP (65). 

The majority of Black clients admitted to treatment for those four drugs 
had multidrug problems; Black clients with a primary problem with heroin 



16 



were more likely than White clients to report a problem with at least one 
other drug. 

Thirty-one percent of Black clients reporting a primary problem with heroin 

at admission reported a secondary problem with cocaine. This figure was 

three times the figure reported by primary White heroin clients as shown in 
Table 2. 

Twenty-seven percent of Black clients admitted to a drug abuse treatment 
program with a primary problem with cocaine reported smoking (or 
freebasing) as their preferred route of administration, compared to five 
percent of White clients. Black primary cocaine clients were more likely 
to report intravenous use than I^Jhites as shown in Table 3. 

It should be noted that this does not include "speedbal 1 ing" which is the 
intravenous combination of heroin and cocaine. Speedbal 1 ing is reported 
with heroin as a primary problem and cocaine as secondary problem. 
Analysis of these data indicate that this particular problem predominates 
among the minority population, particularly Blacks and Puerto Ricans who 
represent 76 percent of speedbal 1 ing admissions. 

Drug abuse-related hospital emergency room cases provide one measure of the 
morbidity associated with drug abuse. While such data cannot provide 
prevalence estimates, per se, they do indicate which drugs are associated 
with medical emergencies. Over time, they indicate if problems associated 
with a particular drug are increasing or decreasing. In addition to 
prevalence, these trends may be influenced by a number of factors, such as 
increased dosages, increased frequency of use, aging of existing users, 
more dangerous routes of administration, and the concomitant use of two or 
more drugs. 

Data on emergency room episodes is collected by the Drug Abuse Warning 
Network (DAWN). This data is gathered in 27 metropolitan areas and a panel 
of emergency rooms outside these metropolitan areas. Since DAWN emergency 
rooms are located primarily in metropolitan areas, they reflect individuals 
who seek emergency room treatment who reside near DAWN participating 
emergency rooms in those areas. Because these facilities do not constitute 
a statistical sample, inferences cannot be made to the general population. 

Of the 96,047 emergency room episodes reported to the DAWN in 1984, 53.7 
percent of the patients were White and 29.7 percent were Black (66). Black 
patients were more likely than were White patients to mention one of the 
major illicit drugs — heroin, cocaine, marijuana, or PCP — in conjunction 
with an emergency room visit. This was generally true for both males and 
females as shown in Table 4. 

The percentages of males reporting use of one of these four major illicit 
drugs was greater than that reported by their female counterparts. It is 



17 



interesting to note that the percent of Black females mentioning heroin, 
18.0 percent, was greater than the percent of White males, 10.2 percent. 

As in treatment admission data. Blacks tended to be older than Whites and 
Hispanics in emergency cases involving cocaine, heroin, and/or marijuana. 
For PCP, however, somewhat similar percentages of Blacks and Whites (49 
percent and 55 percent, respectively) were under 25 years of age. 

Individuals who abuse drugs frequently use two or more drugs (including 
alcohol) in combination. Of the top 10 drug combinations reported by DAWN 
emergency rooms in 1984, 8 of the 10 involved alcohol-in-combinat ion with 
another drug. Cocaine and heroin combinations were the second most 
frequently reported drug combinations. 

Table 5, which shows the 6 of the 10 top combinations that contain an 
illicit drug, incidates that of the patients reporting combination use of 
cocaine and heroin, alcohol and heroin, and alcohol and PCP, Blacks clearly 
predominated. 

Another factor that may contribute to a cocaine-related medical emergency 
is the route used to administer the drug. Consistent with treatment data. 
Blacks were somewhat more likely than were Whites to use the more dangerous 
routes of cocaine administration — injection (used by 49% of Black patients 
and 40% of White patients) and smoking or freebasing (9% of Blacks and 3% 
of Whites) (67). 

The most dramatic recent trend in DAWN emergency room data involves 
cocaine-related cases. Between 1982 and 1984, cocaine-related cases more 
than doubled. Similar trends have occurred in each race/ethnic group. 
Heroin trends have been relatively stable for each race/ethnic group over 
the same period, following substantial increases in the early 1980's. 
Recent increases in PCP mentions, however, have primarily involved Blacks 
and other minorities (51% of all clients mentioning PCP in 1984 were Black 
compared to 46% in 1983) (68). 

The Drug Abuse Warning Network, in addition to providing a measure of 
morbidity associated with drug abuse also provides a measure or mortality 
by providing information on drug related deaths as reported by medical 
examiners in 26 metropolitan areas. Data from the New York metropolitan 
area, whose data were reflected in the emergency room data, are not 
included in mortality data. As with the emergency room component, 
information on decedent demographics, drugs most frequently found in the 
decedents, drug concomitance and preferred route of administration, in 
addition to other types of data, are collected. Also, these data do not 
represent a statistical sample, thus, generalizations to the total 
population cannot be made. 



18 



Of the 3,297 decedents reported to DAWN in 1984, 57.8 percent were White 
and 32 percent were Black. This is two-and-a-half times the proportion of 
Blacks in the United States population (69). 

The two illicit drugs most frequently involved in drug-related deaths among 
Blacks, Whites, and Hispanics were heroin and cocaine. For Blacks 45.3 
percent of the deaths were heroin-related as compared to 23.1 percent for 
Whites. The percentage of cocaine-related deaths cocaine was approximately 
the same for Blacks and for Whites. PCP was not included in the top five 
drugs for Whites, but it ranked number three among Blacks causing 11.9 
percent of the deaths (70). 

Differences among male and female decedents by race (Black, White, and 
Hispanic) are shown in Table 6. It is interesting to note that although 
the actual numbers were much smaller, the percentage of deaths in Black 
females related to heroin, PCP, and cocaine was greater than for Black 
ma 1 e s . 

As with CODAP treatment admissions and emergency room DAWN patients. Black 
decedents tend to be older than l-Jhite or Hispanic decedents in medical 
examiner cases involving cocaine or heroin. For PCP-related deaths. Black 
decedents were older than White decedent (71). 

A majority of DAWN medical examiner reports frequently show combination 
use. The majority of the decedents in cases involving heroin, PCP, and 
cocaine were using other drugs. Eighty-six percent of the Black decedents 
using heroin were using other drugs; 81 percent of White heroin-caused 
decedents used other drugs. For PCP, the percentages were 71 percent of 
Black decedents and 75 percent of White decedents. This distribution 
differs from the one displayed in the emergency room section of this report 
in which a majority of the heroin-related and PCP-related emergency cases 
among Blacks did not involve other drugs. Seventy-six percent of Blacks 
and 68 percent of Whites in cocaine-related deaths were using other drugs 
at the time of death. The most frequently used drugs in combination with 
cocaine were heroin, PCP, and alcohol (72). 

As was the case for emergency room episodes, recent medical examiner data 
involving cocaine show dramatic increases over the past 3 years. Between 
1982 and 1984 cocaine-related deaths among Blacks tripled. Among Whites, 
cocaine-related deaths doubled. Heroin trends have been relatively stable 
over the same period following substantial increases in the early 1980's. 
The recent increases in PCP-related deaths have been primarily involved 
with Blacks and other minorities. The percent of PCP-related deaths 
involving Blacks increased from 50 percent in 1983 to 58 percent in 1984 
(73). 

Health Consequences 

Although there are many commonly known negative health consequences 
associated with drug abuse, there are very few known methodologically sound 
epidemiological case-control studies on the subject that have been done. 



19 



Of those few, they are small, local studies which generally do not look at 
race as a factor. The little information that is known on health 
consequences for Blacks will be reported. 

A recent review of drug abuse patients diagnosed with endocarditis at Cook 
County Hospital in Chicago determined that there was a high degree of 
correlation between intravenous pentazocine and tripelennamine (T's and 
Blue's) abuse and endocarditis caused by Pseudomonas aeruginosa (74). No 
information was given on the racial or ethnic background of the cases; 
however, 1983 data from the Drug Abuse Warning Network showed that 707 of 
818 pentazocine and tripelennamine emergency room episodes occurred in 
Blacks. It is not known if these data are representative of pentazocine 
and tripelennamine users, but to the extent that users are more likely to 
be Black, then Blacks are at greater risk of endocarditis caused by 
Pseudomonas aeruginosa (75). Reports of other hospital-based series occur 
in the literature, but the racial or ethnic characteristics of the 
individuals probably only reflect the characteristics of the population 
served by the hospital (s). 

Some data are available to suggest a drug-homicide relationship. The Crime 
Analysis Unit of the New York City Police Department found that in 1981, 
393 (23.7%) of 1,656 homicides that were able to categorized by 
circumstance in New York City were drug-related. Similarly, in 1982, 349 
(21%) of 1,663 homicides were determined to be drug-related. In 1981 and 
1982, 53.1 and 46.4 percent of drug-related homicides involved Black 
victims (76). Although the racial and ethnic background of perpetrators is 
not known in a large proportion of drug-related homicides, 60 (42%) of 143 
drug-related homicides in 1982 involved a Black victim and a Black 
perpetrator. These results cannot be generalized to other areas of the 
United States; however, they do suggest that Blacks are overrepresented in 
drug-related homicides in New York City. 

There have also been several reviews of medical examiners cases of sudden 
and unexpected deaths. Several reports based on New York City medical 
examiner cases noted marked increase in the number of deaths of narcotic 
addicts from 1967 through 1970, a rise that appeared to parallel a marked 
increase in the addict population (77, 78). Investigation of the 591 
deaths in 1967 that were considered by the Office of the Chief Medical 
Examiner of New York City to have occurred in narcotics users determined 
that 52 percent of the deaths occurred in Blacks and 22 percent in Whites 
(79). A similar investigation of 927 deaths among New York City narcotic 
addicts during a 9-month period in 1971 found that 56 percent of deaths 
were in Blacks, 28 percent were in Whites (80). Since 23.4 percent of the 
population of New York City in 1970 was non-White (81), these figures 
indicate an overrepresentation of Black narcotic addicts' deaths. 

An epidemic of heroin-related deaths that occurred in Washington, D.C. from 
1979 through 1982 was investigated to try to determine the cause of the 
epidemic. A case-control study based on toxicological analyses of 



20 



postmortem blood samples indicated that concentrations of both heroin and 
ethanol were substantial risk factors for heroin-related deaths (83). In 
this epidemic, 93 percent of the decedents were Black; this large 
proportion of Blacks reflects the fact that the population of the District 
of Columbia is largely Black. However, these data suggest that heroin in 
combination with alcohol is an important risk factor for death related to 
heroin use. To the extent that Blacks and other minorities compared with 
Whites are more likely to use heroin in combination with alcohol, they are 
at greater risk of heroin-related deaths. 

Hispanics 

Data from the 1980 census indicate that Hispanics constitute 6.4 percent of 
our population; however, they constitute 10.8 percent of the population of 
the inner cities (41). As such, they may be at a somewhat greater risk of 
drug abuse and its consequences. Results from the 1983 S.R.O. study of 
drug abuse in New York City suggest that Hispanics have higher rates of 
drug use than non-Hispanic Whites for marijuana, cocaine, heroin, an 
illicit methadone. This is important since Blacks and Hispanics constitute 
67 percent of the S.R.O. population compared to 40 percent of the household 
population in New York City. 

The 1982 National Drug and Alcoholism Treatment Utilization Survey (NDATUS) 
suggests that Hispanics are almost three times more likely to be in treat- 
ment for a drug abuse-related problem than are Whites (85). Of the 182,002 
clients admitted to treatment in 1983 and accounted for by the Client 
Oriented Data Acquisition Process (CODAP), 22.3 percent were Hispanic. 

Hispanic clients were more likely than White clients to report a primary 
problem with heroin and PCP. They were also more likely to report "other" 
drugs than White clients. The most common drug included in the "other" 
category is inhalants (see Table 2) (86). 

Recently, it has been suggested that prevalence of inhalant use by Hispanic 
youths is high. While this cannot be supported by household and high 
school population surveys, a 1979 study of Mexican-American children and 
adolescents in Los Angeles barrios found prevalence of inhalants 14 times 
the prevalence found among the general population (87). 

As shown in Table 3, Hispanic clients tend to be younger at admission than 
White clients for the three primary drug categories of heroin, PCP, and 
cocaine. For Hispanics, 21 percent of heroin clients, 73 percent of PCP 
clients, and 46 percent of cocaine clients were under the age of 25 at 
admission compared with 16 percent, 63 percent, and 45 percent for Whites 
(88). With the exception of Hispanic clients reporting a primary cocaine 
problem, Hispanic clients were less likely than were White clients to 
report a problem with at least one other drug at admission (89). 



21 



According to 1984 DAWN data, Hispanic patients were more likely than were 
White patients to mention the four major illicit drugs in conjunction with 
an emergency room visit. This was generally true for both males and 
females as shown in Table 4. 

Sixty-eight percent of Hispanics admitted as emergency room patients for 
PCP-related cases involved persons under age 25. This is a higher 
percentage than for Blacks and Whites (90). 

A majority of DAWN emergency room cases involve the use of two or more 
drugs (including alcohol) in combination. Approximately four out of five 
of the marijuana-related emergency room visits reported to DAWN in 1984 
involved other drugs, with 84 percent of both Hispanics and Whites 
reporting combination marijuana use. Blacks reported lower combination 
marijuana use. For cocaine-related cases Hispanics (60%) and Blacks (61%) 
were somewhat less likely than were Whites (66%) to report such use (91). 

While Hispanics accounted for approximately 9% of all emergency room 
episodes reported to DAWN in 1984, The accounted for 10-24% of those 
episodes incolving drug combinations as shown in Table 5. 

The 1984 DAWN data indicates that those treated for emergency room 
episodes, 42 percent of Hispanics as compared to 40 percent of Whites 
administer cocaine by injection; 6 percent of Hispanics as compared to 3 
percent of Whites administer cocaine by smoking or freebasing. Both are 
more dangerous routes of cocaine administration (92). 

Cocaine-related DAWN emergency room cases more than doubled between 1982 
and 1984 for Hispanics. During those same years, medical examiner data 
involving cocaine show the same dramatic increases. Between 1982 and 1984 
cocaine related deaths among Hispanics tripled, while they doubled among 
Whites (93). 

Of the 3,297 decedents reported to DAWN in 1984, 9 percent were Hispanic. 
Heroin, cocaine, and PCP were the three illicit drugs most frequently 
involved in the deaths among Hispanics with 37.2 percent of the 
heroin-related, 15.8 percent cocaine-related, and 13.4 percent caused by 
heroin and 20.6 percent caused by cocaine. PCP was not included in the top 
five drugs for Whites (94). As with CODAP treatment admissions and 
emergency room DAWN patients, Hispanic decedents were older than White 
decedents in PCP-related deaths. 

The majority of decedents in cases involving heroin or PCP in the DAWN 
medical examiner reports were using other drugs. Seventy-seven percent of 
Hispanic decedents using heroin were using other drugs. This is 4 percent 
less than Whites and 9 percent less than Blacks. For PCP deaths, 70 
percent of Hispanics were using other drugs, again less than both Blacks 
and Whites. This distribution differs from data on emergency room cases in 
which a majority of heroin- and PCP-related emergency cases among Hispanics 



22 



did not involve other drugs. In cocaine-related deaths, Hispanics had the 
highest percentage (79%) of other drug use compared to Whites (68%) and 
Blacks (76%). 

Health Consequences 

Studies on specific health consequences which include Hispanics are even 
more limited than for Blacks. Recently, intravenous use of a "designer" 
drug, MPTP was associated with early onset of chronic Parkinson-type 
disease symptoms in California drug addicts. Identification of individuals 
exposed to MPTP and case ascertainment is still continuing, so that the 
ethnic and racial composition of the cases is not yet known; however, a 
large proportion of the initial cases was Hispanic (96). 

The 1981 and 1982 New York City Police Department Study, mentioned earlier, 
found that in 1981, 34.2 percent of the drug-related homicides involved 
Hispanic victims. In 1982, the percentage of Hispanic victims increased to 
41.8 percent. Although the racial and ethnic background of perpetrators is 
not known in a large proportion of drug-related homicides, 38 (26.6%) of 
143 drug-related homicides in 1982 involved a Hispanic victim and an 
Hispanic perpetrator. These results cannot be generalized to other areas 
of the United States; however, they do suggest that Hispanics are 
overrepresented in drug-related homicides in New York City (97). 

Investigation of the 591 deaths in 1967 in New York City that were 
considered by the Office of the Chief Medical Examiner to have occurred in 
naroctics users determined that 24 percent of the deaths were Puerto Rican 
(defined by Spanish surname) (98). A similar investigation of 927 deaths 
among New York City narcotic addicts during a 9 month period in 1971 found 
that 16 percent of deaths were Puerto Rican (99). 

American Indians/Alaskan Natives 



Data obtained from the 1982 NDATUS suggest that American Indians are almost 
twice as likely to be in treatment for a drug abuse-related problem than are 
Whites (100). 

Treatment data were collected nationally in 1983 on a voluntary basis through 
the Client Oriented Data Acquisition Process (CODAP). The proportion of 1983 
CODAP client admissions (see Table 7), excluding alcohol, was 0.5 percent for 
American Indians and 0.1% for Alaskan Natives. CODAP also indicated that 
American Indian clients were more likely than White clients to report a primary 
problem with heroin, marijuana, or PCP (see Table 8). American Indians also 
were more likely to report the use of "other" drugs than White clients. The 
most common type of "other" drugs category reported was inhalants (101). 

Multidrug usage is also a problem among American Indians according to the CODAP 
data. American Indian clients with a primary problem with heroin were more 
likely than White clients to report a problem with at least one other drug (40.9 
percent of American Indians as compared to 38.6 percent of Whites). Indian 



23 



clients with a primary cocaine problem were also more likely than White clients 
to report a problem with at least one other drug (86 percent of Indians as 
compared to 81.3 percent of Whites). This same greater usage of more than one 
drug was also true of Indians whose primary drug was marijuana. Data on Table 9 
indicates that 80.5 percent of Indian marijuana users used at least one other 
drug whereas 72.7 percent of White clients used at least one other drug (102). 

According to 1984 DAWN data only 212 or 0.2 percent of the 96,047 emergency 
room episodes reported were attributable to American Indians and Alaskan 
Natives (103). The race/ethnic distribution for the 3,297 decedents 
reported to DAWN in 1984 reflects the same percentages as the emergency 
room episodes. That is, only 8 (0.2 percent) of the decedents were 
American Indian/Alaskan Native (104). This low percentage may be explained 
by the fact that DAWN emergency rooms are located primarily in metropolitan 
areas, and a large percentage of American Indians and Alaskan Natives live 
in rural areas. 

Few studies and surveys of drug abuse have focused on minority subgroups of 
the population, however, one survey of American Indian youth, (7th through 
12th grade students in Indian reservation schools) has been conducted 
annually since 1975. Results from this survey for 1980-81 (see Table 10), 
on the lifetime prevalence of substance use for American Indian high school 
seniors show that for 10 of 12 substance categories, American Indians have 
higher lifetime prevalence rates of substance use than high school seniors 
nationally. "Ever-use" of marijuana (88 percent) and inhalants (34.4 
percent) by American Indian seniors, in particular, far exceeds that for 
national high school seniors, which is 59.5 percent and 12.3 percent 
respectively (105). While lifetime prevalence rates provide an indication 
of exposure, figures on frequency of use for a given time period provide a 
better indication of consequences and/or problem use. When frequency of 
substance use for American Indian youth (in grades 7-12) is compared to a 
sample of similarly aged non-American Indian urban youth, a striking 
difference is evident for marijuana. In 1980-81, 13.4 percent of American 
Indian youth reported daily use of marijuana in the 2 months before the 
susrvey as compared with 2.6 percent of the non American Indian urban youth 
(106). 

Asian American/Pacific Islanders 



There is a paucity of data on prevalence of drug abuse among Asian 
Americans. The little informtion that is known suggests that the incidence 
of drug abuse is lower than that of the White population; however, existing 
data are insufficient to draw any definitive conclusions. 

The 1983 treatment data collected through CODAP reported that only 0.8 
percent of all the clients admitted were Asian/Pacific Islanders (107). 

A 1972 investigation of 927 deaths among narcotic addicts in New York City 
during a 9-month period, found that only 2 percent of the deaths were Asian 
American, although a much larger Asian American population resides in the 
area (108). 



24 



CONCLUSION 

In summary, while there is no evidence to suggest that the prevalence of 
drug use differs between Whites and non-Whites in the household population, 
there is evidence to suggest different patterns of use in selected 
treatment and decedent populations. To the degree that particular 
minorities are more involved in intravenous administration and the use of 
drugs in combination, they may be at greater risk of fatal and nonfatal 
consequences of drug abuse and therefore may be suffering disproportionate 
complications associated with drug abuse. To what extent these differing 
patterns of use are affected by environmental conditions such as poverty, 
overcrowding, illiteracy, and unemployment is unknown. What is clear, 
however, is that more epidemiological studies are needed on the causes and 
consequences of drug abuse in all racial and ethnic groups. 



25 



SMOKING 

Cigarette smoking is the chief preventable cause of death in the United 
States. Cigarette smoking is responsible for 30 percent of all cancer 
deaths, nearly 90 percent of all lung cancer, and across all 
smoking-related disease, for over 340,000 premature deaths each year in the 
United States. It is a causative factor in coronary heart disease and 
arteriosclerotic peripheral vascular disease, cancer of the lung, larynx, 
oral cavity, esophagus, and chronic bronchitis and emphezema. It is a 
contributing factor in cancers of the bladder, pancreas, and kidney. 
Cigarette smoking is also associated with ulcer disease and low birthweight 
(109, 110, 111). 

Differences exist in the smoking behavior of minorities and non-minorities, 
and the incidence and gravity of cigarette-related diseases varies. The 
majority of existing data on smoking and minorities is focused on Blacks. 
Less extensive information exists for Hispanics, and very limited data 
exist for American Indians and Asian Americans. Thus, while the report 
will address each minority group, the primary thrust will be devoted to the 
Black population. 

MAGNITUDE OF THE PROBLEM 

Blacks 

Prevalence 



The National Health Interview Surveys (NHIS), conducted by the National 
Center for Health Statistics, are the major sources of data on smoking 
behavior of the United States population. The prevalence of cigarette 
smoking is greater among Blacks than among Whites. 

Across all categories there has been a reduction in the prevalence of 
smokers. In 1965, 52.1 percent of all males age 20 years and above were 
current cigarette smokers; by 1983, 35.4 percent of all males were current 
smokers. 

In 1983, 34.7 percent of White males, 20 years and older, were current 
smokers, whereas, 42.6 percent of Black males were current smokers. The 
higher rate of prevalence among Black males has continued through time from 
1965 to 1983 as demonstrated in Table 11 with a fairly consistant 
differential of approximately 8 percent. The prevalence rate for males, 
both Black and White, declined by approximately 17 percent between 1965 and 
1983. The prevalence of current Black male smokers declined from 59.6 
percent in 1965 to 42.6 percent in 1983. Among White males, the prevalence 
of current smokers declined from 51.3 percent in 1965 to 34.7 percent in 
1983. The disparity in the reduction of prevalence between White and Black 
males has persisted from 1965 to 1983, although it has been fairly constant 
(112, 113). 



26 



Among females, the reduction in smoking prevalence between 1965 and 1983 
was considerably less than for males, (i.e., approximately 4.3 percent vs. 
17 percent). In 1965, 34.2 percent of all females smoked, and in 1983, the 
rate was 29.9 percent. There was a reversal in White-Black prevalence 
during this period as well — in 1965, smoking prevalence among White females 
exceeded that of Black females by approximately 1.8 percent but by 1983 
Black female prevalence was 2.7 percent greater than that of White females. 
While White females have showed a slow but steady decline from 34.5 percent 
in 1965 to 29.8 percent in 1983, Black females have had an 
increase-decrease-increase pattern of smoking prevalence over the years 
(i.e., 32.7 percent in 1965, 34.7 percent in 1976, 30.6 percent in 1980, 
and 32.5 percent in 1983) (114, 115). Table 12 illustrates female 
prevalence rates. 

There has been a steady increase from 1965 to 1983 of former smokers for 
White and Black males (see Table 13) and White females (see Table 14). For 
White males the rate increased from 21.2 percent in 1965 to 32 percent in 
1983. The rate for Black males increased from 12.6 percent in 1965 to 23.2 
percent in 1983. For White females, the prevalence of former smokers went 
from 8.5 percent in 1965 to 17.2 percent in 1983. However, the rate of 
Black female former smokers, although it has increased from 1965 (5.9 
percent), declined from a high in 1980 of 11.8 percent to 10.7 percent in 
1983 (116). 

Combined data from the 1978, 1979, and 1980 cycles of the NHIS indicate 
that two-fifths of Black males (39.1 percent) and nearly three-fifths of 
Black females (59.1 percent) have never smoked. 

The prevalence of never smokers among Whites was lower than that aniong 
Blacks for both genders - 34.3 percent for White males and 54.5 percent for 
White females (117). 

Substantial differences exist between cigarette smoking patterns of Blacks 
and Whites. Differences have been observed in total smoke exposure as 
measured by family income, education level, age of initiation, number of 
cigarettes smoked per day, and tar and nicotine content of cigarettes 
smoked. The following sections will explore those differing patterns. The 
figures used are combined data from the 1978, 1979, and 1980 cycles of 
NHIS. 

Family Income 

There were no consistent relationships between family income and never 
smokers or former smokers for Black or White males. However, it is 
noteworthy that the highest prevalence of never smokers for White males 
(42.4 percent) was in the lowest income level, below $3,000, while the 
lowest prevalence of never smokers among Black males (30.5 percent) was in 
the lowest income level (118). 



27 



Black males had higher prevalence levels of never smokers in all income 
levels except $25,000 and above where the prevalence was similar among 
Black and White males and the less than $3,000 income level where Black 
males were lower in never smoker prevalence. White males had a much higher 
prevalence of former smokers at every level (ranging from 1.5 to 2 times as 
high) than did Black males except for the lowest income level where the two 
groups were similar (119). 

Black males had a higher prevalence of current smokers than did White males 
throughout the range of annual family income levels except $7,000 to 
$10,000. The prevalence of current smokers declined for Black males as 
income increased from less than $3,000 (49,0 percent) to $7,000 to $10,000 
(38.7 percent) and fluctuated thereafter. The prevalence of current 
smokers rose slightly across the range of income levels for White males and 
declined to 34.5 percent in the $25,000 and above income level (120). 

Neither the prevalence of current smokers nor the difference in the 
prevalence of current smokers between Black and White females showed any 
consistent pattern in relation to family income. The prevalence of never 
smokers showed a gradual decline with increased income for White females 
— 60.3 percent at less than $3,000 to 52.0 percent at $25,000 and above. 
Black females had a higher prevalence of never smokers than did White 
females at every income level above $5,000. However, there was not 
consistent relationship between the prevalence of never smokers and income 
level for Black females. The prevalence of former smokers showed no 
consistent pattern in relation to income level for Black females. However, 
the prevalence of former smokers showed a gradual increase with income 
level for White females — 10.7 percent at less than $3,000 to 16.6 percent 
at $25,000 and above. White females were higher in prevalence than were 
Black females in this category at every income level except $3,000 to 
$5,000 annual family income (121). 

Education 



The prevalence of current smokers among both White and Black males rose 
with education level from those with the lowest education level (no 
education) to those who had completed grades 9 to 11. The prevalence rose 
from 36.8 percent for White males with no education to 45.7 percent for 
those with 9 to 11 years of education. The prevalence of current smokers 
among Black males rose from 16.1 percent for those with no education to 
51.4 percent for those with 9 to 11 years of education. Thereafter, the 
prevalence of current smokers declined with education level with the lowest 
prevalence of current smokers among college graduates — 27.0 percent of 
White males and 32.6 percent of Black males. Black males showed a higher 
prevalence of current smokers than did White males at every level of 
education from 1 to 8 years of education to college graduates (122). 

The prevalence of former smokers showed no consistent relationship with 
education level for White males but decreased for Black males up to 9 to 11 
years of education and then increased for high school graduates and beyond. 



28 



The prevalence of former smokers was higher for White males of every 
education level from 1 to 8 years of education to college graduates. The 
prevalence of never smokers generally increased with education level for 
both races with Black males higher at every education level than White 
males. 

The prevalence of current smokers among V/hite females showed the same 
relationship to education level as did White and Black males, increasing up 
to 11 years of education (15.9 percent to 41.6 percent) and decreasing from 
among high school graduates (33.7 percent) to college graduates (24.0 
percent). Black females showed a similar pattern except that those with a 
college degree showed a slight increase in prevalence. Current smokers 
comprised 13.6 percent of Black females with no education, 37.7 percent 
with 9 to 11 years of education, 34.5 percent of high school graduates, and 
34.7 percent of college graduates. Black females had a lower prevalence of 
current smokers than did White females through 9 to 11 years of education 
and a higher prevalence at the level of high school graduates and beyond 
(123). 

White females had a higher prevalence of former smokers at every level of 
education except those with 1 to 8 years of education where Black females 
were higher. The prevalence of those who had never smoked decreased with 
education level up to 9 to 11 years and generally increased thereafter for 
females of both races. Black females had a higher prevalence of never 
smokers at every education level except 1 to 8 years and college graduates 
where Black and White females had a similar prevalence of never smokers 
(124). 

i 

Age of Initiation 

Black and White males and females offered little in the age in which they 
began to smoke regularly. Black and White males started at a median age of 
17.2 years and 17.0 years, respectively. The median age of initiation for 
Black and White females was 18.5 years and 18.3 years respectively. The 
differences between Blacks' and Whites' median age of initiation for both 
genders was about one-fourth of a year with Whites starting just slightly 
earlier than Blacks. In addition, the percentage of smokers starting at 
each age was consistently close for the two races for both genders (125). 

Number of Cigarettes Smoked Per Day 

Although smoking prevalence rates among Blacks are greater than those of 
Whites, heavy smoking (i.e., 25 or more cigarettes per day) is considerably 
more prevalent among Whites. Tables 15 and 16 compare, for males and 
females, the average number of cigarettes smoked per day by White and Black 
smokers in 1965, 1976, 1980, and 1983. 



29 



Among males, the percentage of smokers who smoke heavily increased by 
approximately 9,5 percent between 1965 and 1983, accounting for one-third 
of all male smokers. White males, however, are over three times as likely 
to be heavy smokers as Black males (36.3 percent vs. 11.6 percent) (126). 

Among females, the percentage of smokers who heavily increased by 
approximately 7.5 percent between 1965 and 1983, accounting for one-fifth 
of all female smokers. White females are over four times as likely to be 
heavy smokers as Black females (21.7 percent vs. 5.3 percent) (127). 

From 1965 to 1980 there was a steady increase in the number of heavy 
smokers for all groups, i.e., White and Black males and females. However, 
the 1983 data show a decline in the prevalence of heavy smokers for all the 
groups. 

Type of Cigarettes 

Both Black and White smokers smoked predominantly filter tip cigarettes. 
Among White smokers, 91.7 percent smoked filter tip cigarettes; among Black 
smokers, 90.9 percent smoked filter tip cigarettes (128). 

Tar 



In contrast, both Black males and females smoked cigarettes of higher tar 
content than did either White males or females. Among Black male smokers, 
72.2 percent smoked cigarettes with 15 to 19 milligrams of tar, and 13.1 
percent smoked cigarettes with 20 or more milligrams of tar. By 
comparison, 57.0 percent of White male smokers smoked cigarettes with 15 to 
19 milligrams of tar, and 12.7 percent smoked cigarettes with 20 or more 
milligrams of tar. 

Among Black female smokers, 69.3 percent smoked cigarettes with 15 to 19 
milligrams of tar, and 6.8 percent smoked cigarettes with 20 milligrams or 
more of tar. Among white female smokers, 51.0 percent smoked cigarettes 
with 15 to 19 milligrams of tar, and 6.0 percent smoked cigarettes with 20 
milligrams or more of tar (129). 

Nicotine 

As with tar. Black male and female smokers smoked cigarettes of higher 
nicotine content than did either White male or female smokers. Among Black 
make and female smokers, 84.9 percent and 71.8 percent, respectively, 
smoked cigarettes with a nicotine content of one milligram or more. By 
comparison, 69.9 percent of White males smokers and 53.8 percent of female 
White smokers smoked cigarettes with a milligram or more of nicotine. 

Thus while Black smokers smoked fewer cigarettes than did White smokers, 
they smoked cigarettes of higher tar and nicotine content (130). 



30 



Health Consequences 

Cancer 

Blacks are more likely to develop cancer than Whites or other large 
minority populations in the U.S. (131, 132, 133). This is especially true 
of smoking-impl icated cancers (e.g., oral, pancreatic) and, in particular, 
for the cancer most closely associated with cigarette smoking, lung cancer. 

Data indicate that the incidence of lung cancer among Blacks was, in the 
late 1970's, 20 times higher than it was 40 years previously (134). 
Between 1971 and 1976, the incidence of lung cancer in the Black population 
increased by 24 percent (135). 

Table 17 portrays estimates of Black-White differences in expected lung 
cancer incidence between 1980 and 1990. As indicated, incidence among 
males is expected to increased 21 percent among Whites, compared to 32 
percent among Blacks; among females, a significantly greater increase is 
expected — 86 percent among White females and nearly 99 percent among 
Blacks. 

Looking at lung cancer incidence rates for one year only, 1977, the 
age-adjusted rate for Black males (112.7 per 100,000) was approximately 30 
percent higher than that for White males and approximately 75 percent 
higher than, for example, for Hispanic males. Although the lung cancer 
incidence rate for Black females (28.4 per 100,000) was also higher than 
that for both White and Hispanic females, the rate differentials were 
considerably less than those of the males (Black females were nearly 4 
percent higher than White females and approximately 8 percent higher than 
Hispanic females). As Table 17 indicates, however, these differentials are 
expected to grow (136). 

Blacks are more likely than Whites to die from lung cancer in the U.S. and 
the difference in mortality rates between these two groups is increasing. 
To demonstrate this. Tables 18 and 19 compare, for Whites and Blacks, the 
age-adjusted death rates per 100,000 population for lung cancer in the U.S. 
between 1969 and 1981. 

Among all males, there has been a considerable increase in the rate of lung 
cancer mortality, but the rate of increase in the difference between White 
and Black males has been dramatic. In 1969 there was a mortality rate 
difference of approximately 8 per 100,000 between White males and Black 
males (i.e., 69.9 vs 94.9). The average annual percent increase in 
mortality for Black males between 1969 and 1981 was nearly twice that of 
White males (1.9 vs. 3.4) (137). 

Among females (Table 19), the lung cancer death rates per 100,000 
population more than doubled between 1969 and 1981. There were, however, 
virtually no difference between White females and Black females (i.e., from 



31 



10.3 to 21.7 for Whites and 10.6 to 21.7 for Blacks). Nevertheless, as 
lung cancer incidence rate differences increase between White and Black 
females (Table 17), differences in the mortality rate between these two 
groups will become evident as the year 2000 approaches (138). 

Finally, as was noted earlier, there are areas of considerable difference 
in 5-year cancer survival rates between Whites and Blacks in the U.S. The 
data in Table 20 demonstrate these differences. Among the smoking-related 
cancers listed in this table (i.e., lung/bronchus, esophagus, larynx), the 
survival rate for Blacks is less than that for Whites in each case (i.e., 
10 percent vs. 12 percent, 3 percent vs. 5 percent, and 57 percent vs. 67 
percent, respectively). (139) 

Cardiovascular Disease 

The impact of cigarette smoking on coronary heart disease (CHD) risk in 
Blacks has been examined in small number of studies. A history of 
cigarette smoking was a significant predictor of CHD incidence in Blacks 
and Whites in the Evans County heart disease study. In a 20-year Evans 
County followup, a history of current smoking was also a significant 
independent predictor of death attributed to CHD in Black men. In a 5-year 
study, the 5-year age-adjusted CHD mortality rates were very similar for 
Blacks and Whites at different levels of cigarette consumption, except for 
those who smoked 26-35 cigarettes per day. The study showed a positive 
association between cigarette smoking and CHD mortality. In the American 
Cancer Society prospective study of one million Americans followd for 12 
years (1960-1972), about 25,000 Blacks were enrolled. CHD mortality ratios 
in subjects grouped according to the number of cigarettes smoked were 
similar at given smoking levels in Black and White men, and slightly lower 
in Black women as compared to White women. There was, however, evidence of 
an enhanced effect of smoking on the risk of CHD death in individuals with 
a history of high blood pressure or other cardiovascular disease. This is 
significant because there is a high prevalence of hypertension in the U.S. 
Black population (140). 

Blood pressures are higher in Black men than in White men. In addition, 
an excess of definite hypertension, borderline hypertension, and isolated 
systolic hypertension is seen in Blacks compared to Whites. The most 
recent national data show that, among adults ages 18-74 years, the 
prevalence of definite hypertension in Blacks is 1.4 times that observed in 
the White population. The prevalence of borderline hypertension is 11.9 
percent for White adults and 12,5 percent for Black adults in the 18-74 
year age range. The prevalence rate of isolated systolic hypertension in 
Blacks ages 54-74 was 8.1 percent as compared to 4.8 percent among White 
adults of the same ages (141). 

As a result of the increased incidence of hypertension among Blacks, Blacks 
who smoke and have a history of high blood pressure are at an increased 
risk of dying from coronary heart disease. 



32 



Antecedents of Smoking and Characteristics of Smokers 
in the Black Population 

As may be seen above, there is a reasonable body of reliable, 
population-based data available which characterizes the smoking-related 
cancer risks and smoking patterns in the U.S. Black population. There is, 
however, considerably less information available dealing with the activity 
and predictive character of the events leading up to this behavior and 
descriptions of those who are at risk through their smoking. Nevertheless, 
limited data are available, the most relevant of which are summarized 
below. 

In an effort to determine the antecedent conditions that predispose Black 
youth to smoke, Brunswick and Messeri used a multidimensional ecological 
model of influence on behavior of Harlem youth. Predictors were assessed, 
and between 6 and 8 years later smoking outcome was measured. For boys, 
four variables were most strongly predictive of future teenage smoking: 
higher peer orientation, poorer expectations for personal achievement, 
pessimism about changes for the world becoming better, and the tendency to 
report more good health practices earlier in adolescence. For girls, the 
four predictors were recent migration from the south, poor scores on 
standardized reading tests, shorter time perspective (indicative of a 
future orientation), and higher levels of food consumption (142, 143). 

The Harlem youth study also suggests a strong relationship between 
educational level and both the initiation and the subsequent extent of 
smoking. Smoking rates for tenth-grade dropouts were higher than for high 
school graduates. Lower scholastic achievements prior to the onset of 
smoking was observed, with a stronger relationship between the two for 
girls than for boys. Worrying about school made an independent 
contribution to the initiation of smoking by girls. 

In another study of smoking patterns among children, the Bogalusa Heart 
Study reported that Black children lag behind White children in early 
experience of and adoption of smoking behavior. White children were more 
influenced by parents, and Black children were more influenced by peers and 
siblings in their smoking behavior (144). 

A 1980 American Cancer Society-sponsored survey of 750 Black men and women 
revealed several motivational factors involved in cigarette smoking (145). 
More than one-third of the smokers interviewed reported that they smoked in 
order to relieve tension; about half reported that, for them, smoking was 
very enjoyable (one-third, fairly enjoyable); and about one-third of 
non-smokers and one-half of smokers expressed the belief that they are 
likely to get lung cancer. 

The American Cancer Society study also reported that Blacks were more 
interested than Whites in giving up smoking (30 percent compared with 24 
percent). Interest in quitting was highest for Black women and for higher 



33 



income levels ($15,000+). Blacks also felt quitting would be less 
difficult than did Whites (39 percent compared with 22 percent). However, 
as the data in Tables 13 and 14 indicate. Whites are considerably more 
likely than Blacks, among males and females, to be former smokers. 

Finally, in a study which considered the psychological and social 
correlates of smoking patterns among Black females, the following 
observations were made: personalization of risk was not the trigger event 
that led to smoking cessation, though it occurred later as part of the 
decision to change behavior; quitters believed that smoking is related to 
disease; successful quitters reported the most sources of information about 
the relationship between smoking and disease, especially through the mass 
media and interpersonal sources; and suffessful quitters were most likely 
to have mothers and sisters who were non-smokers (146). 

Hispanics 

Preval ence 

Overall prevalence rates of smoking among Hispanics are the lowest reported 
among the groups compared. Data from the 1980 NHIS indicate an overall 
prevalence rate of 31.0 percent for Hispanics, 34.5 percent for Whites, and 
36.9 percent for Blacks. However, when male and female prevalence rates 
were separated, Hispanic males were found to report higher rates in every 
category except Black males. Hispanic women reported the lowest rates for 
all groups. The 1980 NHIS data report 40.9 percent of Hispanic males to be 
current smokers, 38.2 percent for White males, and 45.0 percent for Black 
males. Only 22.9 percent of Hispanic females are current smokers, whereas 
31.4 percent White females and 31.9 percent of Black females are current 
smokers (see Table 20 for further details) (147). The 1979 California 
Hypertension Survey and the San Antonio Heart Study (148) confirm these 
results. In a combined sample of the 1976 and 1977 Los Angeles Health 
Survey, overall Hispanic smoking prevalence was, as is usually reported, 
the lowest among the groups compared (White, Hispanic, Blacks). However, 
Hispanics males were found to report the highest rates among the three 
groups with 41.5 percent current smokers being Hispanic males, 40.0 percent 
Black males, and 39.3 percent White males (149). 

The differential in smoking rates between Hispanic males and females holds 
true for Puerto Ricans, Mexican/Mexico-Americans, other Latin Americans, 
and "other Spanish" according to 1979-1980 combined samples of Health 
Information Survey data analyzed for percent of current smokers by sex and 
Spanish origin (150). (The HIS uses the term "Spanish Origin" as an 
umbrella terra for those of Latino and/or Spanish ancestry). 

The assumption that cigarette smoking is not a problem for U.S. Hispanics 
is based on data examining adult prevalence. Youth are relatively ignored 
and yet it is among this group that the greatest opportunity either for 
cancer prevention or development of cancer in the next century exists. 



34 



The data that are available suggest that the current generation of Hispanic 
youth — male and female alike — may not significantly differ from their 
White/Anglo or Black counterparts, either in smoking prevalence or, 
consequently, in cancer incidence. Results from a 1982 study and a 1984 
study of Mexican American youth show a marked increased in smoking among 
these youths. More of the Mexican-American youths smoke than their Black 
and White peers (i.e., 28.9 percent vs. 15.2 percent and 19.1 percent 
respectively) (151). 

D'Onofrio et al . and Rivers and McCoy each reporting on limited surveys 
suggest that Hispanic adolescents, in Northern California and South Florida 
respectively, equal or exceed other adolescent groups in smoking 
prevalence. Marcus and Crane examined data from the 4th and 5th 
grade-based Los Angeles "Know Your Body (KYB)" program, and found (see 
Table 22) that male and female Hispanics exceeded both male and female 
Whites and Blacks in self-reported current cigarette use (152). 

These data suggest that the smoking prevalence of Hispanic youth needs to 
closely monitored and that when the issue of "Hispanic" smoking is 
considered, that the problem of adolescent use not be ignored just because 
the overall Hispanic data are not considered to be as problematic as that 
for other groups. 

Type of Cigarettes Smoked 

In a study done in New Mexico from 1980 to 1982 comparing Hispanics to 
non-Hispanics, among males and females of both ethnic groups, filter 
cigarettes had been smoked longer by subjects younger than 70 years; 
whereas non-filter use predominated in subjects 70 years and older. Older 
Hispanic males and females had used handrolled cigarettes for a much longer 
period of time (14.7 years longer for Hispanic males over 70 and 8.8 years 
longer for Hispanic female smokers over 70.). Data from this study and 
Buellj et al., while not definitive, suggest that the use of handrolled 
cigarettes may explain the excess lung cancer mortality and incidence in 
older Hispanic women in the southwest (153). 

Number of Cigarettes Smoked Per Day 

In addition to smoking prevalence, consumption of cigarettes has 
significance for the public health implications of smoking behavior. In 
Table 23 consumption levies obtained from the 1979-1980 HIS are reported 
separately by sex and race/ethnicity. Among both male and female smokers, 
Hispanics are much more likely to consume 10 or fewer cigarettes per day, 
while their White counterparts are much more likely to smoke over 20 
cigarettes per day (154). The New Mexico study confirm these lower 
consumption levels. 

The New Mexico study data indicate that New Mexican Hispanic males and 
females in all the age cohorts smoke fewer average daily cigarettes than 



35 



the non-Hispanic subjects. The older the study population, the greater the 
difference. In the males 55 years and under group, there was only a 
difference of one cigarette a day. The difference increased to 8 
cigarettes a day fewer for male Hispanics ages 55 to 69 and 13 fewer a day 
for the over 70 cohort. Hispanic females under 55 years smoked 9 fewer 
cigarettes a day; 2 cigarettes fewer in the 55-60 age cohort; and 15 
cigarettes fewer a day in the over 70 age cohort (155). 

Health Consequences 

Lung and esophageal cancer morbidity and mortality rates, known to be 
related to smoking, are lower for Hispanics than for non-Hispanic Whites 
and Blacks. According to SEER data collected from 1978 to 1981, Hispanics 
had the lowest incidence rate for cancer of the esophagus. However, an 
anomaly exists among New Mexico Hispanic females where the incidence of 
esophageal cancer is 20 percent higher. Studies suggest a link between the 
development of esophageal cancer and smoking and alcohol consumption, with 
the latter two having a syaergestic effect. 

SEER data indicate that the lung cancer incidence rate for New Mexican 
Hispanics is half the incidence rate for Whites, and for Puerto Rican 
Hispanics the incidence rate is less than half that of Whites. New Mexico 
Hispanics have rates of cancer of the pancreas that are higher than those 
of Whites. An upward trend for pancreatic cancer in Puerto Rican females 
is becoming apparent. Excess risk for this cancer has been found among 
cigarette smokers (156). 

While Hispanic men appear to be smoking as frequently as their White 
counterparts, their reported consumption levels would seem to be lower. 
Since there is a case-response relationship between consumption of 
cigarettes and lung cancer, these data might suggest that the epidemiologic 
consequences of Hispanic smoking will be minimized. It is important to 
note that even light to moderate smokers have rates of lung cancer that are 
two to four times higher than non-smokers (157). Moreover, there are no 
assurances that Hispanics in general will continue to maintain this 
relatively low consumption pattern. Indeed, the surveys of Hispanic 
adolescents in Northern California and South Florida indicate smoking 
prevalence levels which equal or exceed other adolescent groups. 

Hispanics, as a group, appear to be at lower risk for coronary heart 
disease. Consequently, there is no evidence of increased risk of 
cardiovascular disease among Hispanics as a result of smoking behavior (see 
the Subcommittee Report on Cardiovascular Disease in Minorities for more 
detail) (158). 

The findings summarized above suggest that rates of lung cancer and other 
cigarette-linked diseases among Hispanic males may increase within this 
decade, and continue to increase into the next century. The current lower 
rate of lung cancer among Hispanics of today reflect a period in time when 



36 



Hispanics smoked less frequently than Whites. Current evidence suggest 
that Hispanic males are now as likely to be smokers as their White 
counterparts. 

American Indians/Alaskan Natives 

Prevalence 

Very little is known about smoking prevalence and patterns in American 
Indian and Alaskan Natives due to the scarcity of data. The available 
information is available will be discussed below. 

Data do exist for Native American high school seniors and the prevalence of 
smoking among this population. Based on a study that compared the lifetime 
prevalence of substance use for American Indian high school seniors and 
national high school seniors, between 1980-81, Native American high school 
seniors exhibited a prevalence rate of cigarette smoking of 72.3 percent as 
compared to 71.0 percent for national high school seniors (166). These 
data suggests that the prevalence of smoking in Native American youth is 
similar to the prevalence of smoking for youth nationally. 

A 1968 study documented cigarette and alcohol use patterns in American 
Indians in a report based on interviews of patients at the Phoenix Public 
Health Service Hospital. The findings indicated that heavy cigarette 
smoking (i.e., more than one pack a day) was rare among Southwestern 
Indians, that smoking habits of non-Southwestern Indians were similar to 
those of the general population, and that Indian women outside the 
Southwestern area were likely to be heavy smokers (167). While this study 
is quite dated, however, current cancer and coronary heart disease (CHD) 
incidence and mortality rates reflect these same patterns of smoking. 

Health Consequences 

Overall, American Indians and Alaskan Natives have smoking-rel ated cancer 
rates below Whites for lung cancer; hov/ever, the relative frequency of lung 
cancer differs among tribes. For example, among Oklahoma Indians, where 
the lung cancer standardized mortality ratio is higher, both cigarette 
smoking and lung cancer mortality more closely mirror the national average. 
In contrast, Indians of the southwest, who seldom smoke have low rates of 
smoking-related lung cancer (168). Environmental and cultural factors 
undoubtedly play a role in this discrepancy — those populations having 
substantially non-Indian ancestry and living off reservations (principally 
tribes in Oklahoma) have mortality for most sites that is between the 
national average and the rates of tribes in the southwest living on the 
reservations and of mostly Indian heritage. 

In terms of CHD, American Indians and Alaskan Natives show evidence of 
reduced heart disease mortality in males and females compared to the 



37 



comparable White populations. Mortality from heart disease is 
significantly lower than for Black males and females (169), at all ages. 

Preliminary prevalence and incidence data suggest that coronary heart 
disease and stroke risk may be increasing substantially in this population, 
especially among those residing outside the southwestern states (170) which 
is reflective of the smoking patterns previously identified. 

The heart disease death rate for American Indians under 35 years of age is 
approxiamtely twice as high as for all other groups. However, above the 
age of 35 years, heart disease mortality increased much less steeply with 
age in Indians than in the general population. By age 45, the mortality 
rates for this group are lower than those in all other groups and continue 
in that pattern for all the remaining age cohorts. The excess mortality 
rates due to cirrhosis of the liver, homicide, and accidents among American 
Indians raises the possibility that the reduced mortality for coronary 
heart disease and cancer may be due, at least in part, to competing causes 
of death rather than to a basic reduction in CHD and cancer risk. 

Asian Americans/Pacific Islanders 



Prevalence 

Due to the paucity of data very little is known about the prevalence of 
smoking or smoking patterns among Asian/Pacific Islanders. Only a few very 
limited studies are available. Because of the restricted nature of the 
study area and population, the information must be viewed cautiously and 
should not be generalized. 

In a 1979 survey of Japanese Americans in California, 50.6 percent of the 
Japanese-American men were classified as "ever smoked" (159). Using the 
1980 HIS data and combining current and former smoker statustics (see Table 
11 and 13) for White males, approximately 69 percent of White males could 
be classified as "ever smoked." Data on smoking from a small study by 
Shiriki and Savage (1984) on Chinese-Americans show that fewer young 
Chinese males were smokers than young White males (26.6 percent vs. 34.6 
percent) but more older Chinese males were smokers than older White males. 
In all the age cohorts, a significantly larger percentage of White females 
smoked than Chinese-American females. Regardless of age and gender. Whites 
smoked more cigarettes on the average than Chinese-Americans (160). 

Data from California on the prevalence of smoking and patterns of smoking 
among younger and older Filipino males and females compared to Whites show 
that fewer Filipino males and females in all age groups are current regular 
smokers as compared to their White counterparts (26 percent vs. 63 percent, 
respectively, among males and 14.3 percent vs. 29.4 percent among 
females). Filipino males smoked 17.7 cigarettes on the average vs. 27.4 
cigarettes smoked by White males. Filipino females smoked 8.0 cigarettes 
vs. 23.2 cigarettes smoked by White females. 



38 



Of those who were smokers, slightly more Filipino males than White males 
expressed a desire to quite smoking though comparable or fewer Filipino 
females wanted to quite smoking than White females (161). 

In sum, the Filipino,, Japanese, and Chinese Americans in California have, 
in general, a lower prevalence of smokers and smoke less than their White 
counterparts. 

Health Consequences 

On the basis of both published and unpublished National Center for Health 
Statistics data, the Heart Association Report on Cardiovascular Disease 
Mortality in Los Angeles County data, and data from the Honolulu Heart 
Study, it appears that Asians are at a lower risk of mortality from 
cardiovascular disease than Whites and other minorities. Among Asians, 
women appear to be at lower risk than men across all groups, and Koreans, 
Filipinos and Chinese appear to be at lower cardiovascular disease risk 
than both Japanese men and women (162). (See the Cardiovascular Disease 
Subcommittee Report for more detail.) 

Although Asian Americans have a lower incidence of cardiovascular disease, 
certain subgroups within the Asian population do exhibit excess incidence 
and mortality or some smoking-related cancers. For example, Hawaiians have 
excess incidence and mortality for cancer of the lung. Lung cancer is 
associated with cigarette smoking. This high cancer rate is closer to the 
rates of Blacks and Whites than to those of Chinese, Japanese, or Filipinos 
(163). Since this is based on a small number and may be artifically 
inflated, these figures should be viewed with caution. 

The incidence of esophageal cancer is higher for Japanese males and Chinese 
males and females than for Whites. The rate for Japanese males is 2.5 
times higher, for Chinese males it is 1.8 times higher, and for Chinese 
females it is 1.6 times higher. Most studies into the causes of esophageal 
cancer suggest that the major risk factors are smoking and alcohol 
consumption, with the use of both having a synergistic effect; although, 
the consumption of hot beverages also has been associated with esophageal 
cancer. In addition, in Japan a strong direct relationship was found 
between esophageal cancer and high intake of tea-cooked rice gruel (164). 

Pancreatic cancer incidence is about 20 percent higher among Chinese 
females than among Whites, and an upward trend in incidence exists for 
Chinese of both sexes. Japanese, particularly Japanese females, show 
considerably lower incidence than Whites. Excess risk for pancreatic 
cancer has been found among cigarette smokers, and some studies have 
suggested a link with diabetes mellitus (165). 

While prevalence rates of smoking for Asian Americans are virtually 
unknown, it is clear than an increased incidence for certain 
smoking-related cancers exist among subgroups of the Asian population. 
Because so little is known about the smoking behavior of Asians, data needs 
to be collected to understand the extent and nature of the health 
consequences related to smoking in this population. 



39 



CONCLUSIONS AND OPPORTONITIES FOR PROGRESS 



The various forms of chemical dependency discussed in this chapter, alcohol 
abuse, illicit drug abuse and smoking, are known to have a major adverse 
impact on the health status of the general population. As this chapter has 
explored. Blacks and other minority populations (Hispanics, Asian Americans 
and Native Americans) may not be at an eqiial risk compared to the general 
population for the adverse health consequences of these chemical 
dependencies. 

Mortality rates in minority populations due to cirrhosis of the liver, 
various cancers and unintentional injuries which are associated with 
certain substance abuses exceed those for the general population. While 
excess adverse health consequences and death rates associated with chemical 
dependency cannot be attributed solely to minority status, and though all 
persons of a particular minority group are not at equal risk for these 
outcomes, it is clear that alcohol abuse, illicit drug abuse, and smoking 
contribute to the overall poorer health status of minority populations. 

Although the prevalence rates of smoking for Asian/Pacific Islanders are 
unknown, it is clear that an increased incidence for certain smoking- 
related cancers exist among subgroups of the Asian population. 

Opportunities for Progress 

Interventions proposed by the Subcommittee follow: 

• Promote the initiation and/or expansion of efforts to develop 
coping skills in children and adolescents, ages 9 to 15 years, to 
delay or prevent the use of substances such as tobacco, drugs, and 
alcohol, with special emphasis on the needs of minorities. 

• Foster the development of peer-group instruction programs in 
school settings designed to strengthen resistance to the use of 
substances such as tobacco, drugs, or alcohol, with special 
emphasis on the needs of minorities. 

• Perform research into cirrhosis, including studying the basic 
biological mechanisms involved in the development of cirrhosis of 
the liver in Black, Native American, and Hispanic populations. 

• Develop programs to prevent alcohol-related unintentional death 
and injury among Blacks, Hispanics, Native Americans, and Native 
Hawaiians. Epidemiological research is needed to define further 
the subpopulations of each minority group that are at greatest 
risk so that prevention and education efforts as well as early 
intervention and treatment programs can be developed and targeted 
with greater likelihood for success. 



40 



• Investigate the biological consequences of alcohol use in terms of 
its contribution to excess mortality among minority groups. The 
role of alcohol use in hypertension, the role of alcohol use in 
the development of some cancers in Blacks, and the extent to which 
alcohol is a factor in the adverse pregnancy outcomes among all 
minority groups, especially Black and Native American women, are 
suggested topics. 

• Determine the nature and extent to smoking among Hispanics, Native 
Americans, and Asian/Pacific Islanders so that the health 
consequences associated with smoking in these populations might be 
understood and appropriate prevention strategies developed. 

• Study the prevalence, etiology, and consequences of drug abuse 
among Blacks, Hispanics, Native Americans, and Asian/Pacific 
Islanders through case-control cohort, or historical cohort 
epidemiological studies utilizing culturally sensitive 
instruments. 

• Develop improved incidence and prevalence data gathering 
techniques to assess alcohol and drug abuse among all minority 
groups . 

• Develop mechanisms in concert with appropriate state and local 
entities to support specialized drug abuse prevention and treat- 
ment program in rural and urban Native American/Alaska Native 
communities. 

• Encourage Blacks to enter smoking cessation programs and maintain 
cigarette abstinence. 

• Review DHHS health professionals' training programs to ensure the 
inclusion of education about alcohol and drug abuse in the 
curricul a. 

• Provide assistance to appropriate organizations for health care 
professionals to ensure that education on alcohol and drug abuse 
is included in their training curricula. This includes training 
in the diagnosis and prevention of alcohol and drug abuse in a 
variety of patient populations, incuding ethnic minorities; in 
referring patients to appropriate treatment settings; and, in the 
provision of direct service and treatment that is relevant to the 
specific minority patient. 

• Encourage private sector organizations to train minority research 
scientists and health care providers in substance abuse research, 
diagnosis, and treatment. 



41 



Table 1 

Marijuana Use for Whites and Minorities by 

Age Group for 1977, 1979, and 1982 

National Surveys on Drug Abuse 



Marijuana Use for the Year 
Preceding the Surveys 

Minorities 





Age Groups 








Young 


Mid 


Older 


Youth 


Adults 


Adults 


Adults 


Youth 


Adults 


Adults 


Adults 


12-17 


18-25 


26-34 


over 35 



1977 
1979 
1982 



17% 


33% 


26% 


3% 


21 


37 


20 


7 


16 


40 


21 


4 



White 



1977 
1979 
1982 



24% 


40% 


21% 


2 


24 


47 


25 


3 


21 


40 


28 


5 



Minorities include respondents who identified themselves as Black, 
American Indian, or Alaskan Native, Asian or Pacific Islander, or 
Hispanic 



42 



TABLE 2 

Percent Distribution of Primary Heroin Clients by 

Secondary Drug of Absue According to 

Select Race/Ethnicity Groups 

at Admission 

CODAP, 1983* 

Secondary Drug 

None 

Other Opiates 

Marijuana 

Barbiturates 

Amphetamines 

Alcohol 

Cocaine 

PCP 

Other Hallucinogens 

Tranquilizers 

Other Sedatives 

Other 



Primary 


Heroin 


White 


Black 


61.5% 


45.9% 


12.2 


7.0 


4.3 


4.7 


1.3 


0.8 


1.8 


2.5 


5.6 


6.1 


10.1 


30.7 


0.4 


0.2 


0.2 


0.1 


1.7 


0.8 


0.9 


0.5 


0.2 


0.8 



*Based on 23 States, Washington, D.C., and territories; 
California represented 46 percent of treatment admissions. 



43 



Table 3 

Percent Distribution of Primary Cocaine Clients 

by Route of Administration According to 

Selected Race/Ethnicity Groups at Admission 

CODAP, 1983* 

Primary Cocaine 

Route of Administration White Black 

Oral 

Smoking (freebasing) 

Inhalation 

Intramuscular 

Intravenous 



2.3% 


1.3% 


5.3% 


27.4 


66.9 


41.4 


0.7 


0.5 


24.8 


29.4 



*Based on 23 States, Washington, D.C., and territories; California 
represented 46 percent of treatment admissions. 



44 



TABLE 4 

Most Frequently Mentioned Drug Categories 

for Emergency Room Patients 

According to Race and Sex 

(alcohol-in-combi nation excluded) 

DAWN, 1984* 



Black 


Male 


i 


(N episodes 


= 16,121) 


Heroin 




32.9% 


Cocaine 




19.1 


PCP 




15.6 


Marijuana 




6.3 


Diazepam 




2.5 


Hispanic Ma] 


1 e 


(N episodes 


= 4, 


700) 


Heroin 




25.4% 


Cocaine 




20.6 


PCP 




15.4 


Marijuana 




7.0 


Diazepam 




5.5 



Black Female 



(N episodes 


= 


12,325) 


Heroin 

Cocaine 

PCP 

Acetaminophen 

Diazepam 


18. 

11, 
8. 
6, 
6. 


,0% 

,9 

,8 

.4 

,3 


Hispanic 


Female 




(N episodes 


= 


4,074) 


Diazepam 

Acetaminophen 

Heroin 

Cocaine 

Aspirin 


9, 
9. 
8, 
8. 
8^ 


.5% 

.5 

.8 

,6 

.1 



(N episodes = 22,955) 



(N episodes = 28,521) 



Diazepam 


11.9% 


Cocaine 


11.4 


Heroin 


10.2 


Marijuana 


6.5 


PCP 


4.7 



Diazepam 


12.5% 


Aspirin 


8.8 


Acetaminophen 


7.1 


Cocaine 


5.0 


Heroin 


4.3 



*Based on 27 metropolitan areas and a panel of emergency rooms outside 
these metropolitan areas; generalizations to total population cannot be 
made. 



45 



TABLE 5 



Sex, Race, and Age Distributions for Six Leading 
Combinations of Illicit Drugs 
in DAWN Emergency Rooms 
January-August 1984* 



Cocaine 


Alcohol 


Alcohol 


Alcohol 


and 


and 


and 


and 


Heroin 


Cocaine 


Heroin 


Marijuana 



Cocaine Alcohol 

and and 

Marijuana Marijuana 



Sex 



27 


48 


26 


53 


49 


29 


55 


35 


57 


31 


34 


56 


13 


12 


14 


10 


13 


12 



Percent Male 70 65 81 70 71 74 

Race 

Percent White 
Black 
Hispanic 

Age 

Percent 20 

20-29 
30 

Total Number 1,442 1,320 1,316 1,139 922 818 



2 


9 


1 


29 


18 


11 


43 


53 


28 


49 


56 


60 


55 


37 


71 


24 


26 


29 



*Based on 27 metropolitan areas and a panel of emergency rooms outside these metropolitan area 
generalizations to total population cannot be made. 



46 



TABLE 6 

Most Frequently Mentioned Drugs by 
Decedents According to Race/Ethnicity and Sex 
(alcohol-in-combination excluded) 
DAWN, 1984* 



Black Male 



Black Female 



(N episodes 


= 


818) 


Heroin 




43.8% 


Cocaine 




18.6 


PCP 




10.9 


Codeine 




7.3 


Diazepam 




2.8 


Methadone 




2.3 


Hispanic 


Male 


(N episodes 


= 


258) 


Heroin 




38.8% 


Cocaine 




15.5 


PCP 




12.8 


Codeine 




4.7 


Diazepam 




4.3 


D-Propoxphene 


2.7 


White mal( 


3 



(N episodes = 1,181) 

Heroin 28.9 

Cocaine 25.6 

Codeine 15.7 

Diazepam 12.5 

D-Propoxyphene 9.5 

Methadone 8.9 



(N episodes = 


235) 


Heroin 


50.6% 


Cocaine 


22.6 


PCP 


15.7 


Codeine 


12.3 


Amitriptyline 


11.1 


Phenobarbital 


8.1 


Hispanic Female 


(N episodes = 


40) 


Heroin 


27.5% 


Cocaine 


17.5 


PCP 


17.5 


Methadone 


12.5 


Diazepam 


10.0 


D-Propoxphene 


10.0 


White Femal 


e 


(N episodes = 


723) 


D-Propoxyphene 19.5 


Amitriptyl ine 


17.4 


Codeine 


13.8 


Heroin 


13.6 


Cocaine 


12.6 


Acetaminophen 


11.8 



*Based on 26 metropolitan areas, excluding New York; generalizations to 
the total population cannot be made. 



47 



TABLE 7 

Distribution of 182, 002 CI ients by Race/Ethnicity 
at Admission (excluding alcohol) 
CODAP, 1983* 



Race/Ethnicity 

White 

Black 

Hispanic 

American Indian 

Alaskan Native 

Asian/Pacific Islander 



No. Client 




Admissions 


Percent 


98,504 


54.1 


40,538 


23.4 


40,625 


22.3 


862 


0.5 


12 


0.1 


1,461 


0.8 



*Based on 23 States, Washington, D.C., and territories; California 
represented 46 percent of treatment admissions. 



48 



TABLE 8 

Percent Distribution of Clients by 

Primary Drug According to Race/Ethnicity 

at Admission (excluding alcohol) 

CODAP, 1983* 



Primary Drug 


White 


Black 


Heroin 


43.8% 


60.3% 


Other Opiates 


8.5 


3.4 


Marijuana 


19.1 


12.0 


Barbiturates 


2.0 


1.2 


Amphetamines 


9.0 


2.9 


Cocaine 


8.3 


9.7 


PGP 


2.2 


7.1 


Other Hallucinogens 


1.5 


0.3 


Tranquil izers 


2.0 


0.7 


Other Sedatives 


2.2 


0.5 


Other 


1.5 


1.9 


TOTAL 


98,504 


40,538 



Hispanic 
70.6% 

1.0 
13.0 

0.5 

1.2 

2.8 

7.8 

0.3 

0.3 

0.3 

2.1 
40,625 



American Indian 
44.8% 

2.3 
27.4 

1.0 

5.6 

5.0 

5.0 

1.0 

1.0 

1.2 

5.2 

862 



*Based on 23 States, Washington, D.C., and territories; California 
represented 46 percent of treatment admissions. 



49 



TABLE 9 

Percent of Distribution of Clients by Age 

According to Race/Ethnicity Selected Primary Drug 

CODAP, 1983* 



Whi te 



Black 



Primary Drug 


Under 25 


25 


and Over 


Under 25 


25 


and Over 


Heroin 


16.1 




83.9 


8.2 




91.8 


Cocaine 


45.2 




54.7 


31.0 




69.0 


Marijuana 


76.4 




23.6 


68.5 




31.5 


PCP 


63.3 




36.7 


47.4 




52.6 



Hispanic 



American Indian 



Primary Dn 


il 


Under 24 


24 


and Over 


Under 24 


24 


and Over 


Heroin 




21.4 




78.6 


17.1 




82.9 


Cocaine 




46.4 




53.6 


39.5 




60.5 


Marijuana 




74.4 




25.6 


83.1 




16.9 


PCP 




73.4 




26.6 


69.8 




30.2 



*Based on 23 States, Washington, D.C., and territories, California 
represented 46 percent of treatment admissions. 



50 



TABLE 10 

Lifetime Prevalence of Substance Use for 
American Indian High School Seniors 
and National High School Seniors 
1980-81 





Ame 


rican Indian 


National 




High 


School Seniors 


High School Seniors 


Substance 




1980-81 


1981 


Alcohol 




95.3% 


92.6% 


Marijuana 




88.0 


59.5 


Cigarettes 




72.3 


71.0 


Inhalants 




34.4 


12.3 


Stimulants 




38.5 


16.5 


Cocaine 




19.4 


16.5 


Sedatives 




12.0 


16.0 


Hallucinogens 




19.1 


13.3 


Tranquil izers 




11.0 


14.7 


PCP 




10.2 


7.8 


Heroin 




2.4 


1.1 



Source: Getting ER, Beauvais F, Edwards R, et al . Drug use among Native 

American youth: Summary of findings (1975-1981). Fort Collins, CO: 
Western Behavioral Studies, Colorado State University. 



51 



TABLE 11 



Current Cigarette Smokers Among Males 20 Years of Age 

and Over, by Race; 

United States, 1965, 1976, 1980, 1983 



Race Current Smokers 

1965 1976 1980 1983 

All Males 
White Males 
Black Males 



Source: National Health Interview Surveys, National Center for Health 
Statistics. 



52.1 


41.6 


37.9 


35.4 


51.3 


41.0 


37.1 


34.7 


59.6 


50.1 


44.9 


42.6 



52 



TABLE 12 



Current Cigarette Smokers Among Females 20 Years of Age 

and Over, by Race; 
United States, 1965, 1976, 1980, 1983 



Race Current Smokers 



1965 1976 1980 1983 



All Females 
White Females 
Black Females 



34.2 


32.5 


29.8 


29.9 


34.5 


32.4 


30.0 


29.8 


32.7 


34.7 


30.6 


32.5 



Source: National Health Interview Surveys, National Center for Health 
Statistics. 



53 



TABLE 13 



Former Cigarette Smokers Among Males 20 Years of Age 
and Over, by Race; 
United States, 1965, 1976, 1980, 1983 



Race Former Smoker 



1965 1976 1980 1983 



All Males 
White Males 
Black Males 



20.3 


29.6 


30.5 


31.1 


21.2 


30.7 


31.9 


32.0 


12.6 


20.2 


20.6 


23.2 



Source: National Health Interview Surveys, National Center for Health 
Statistics. 



54 



TABLE 14 



Former Cigarette Smokers Among Females 20 Years of Age 
and Over, by Race; 
United States, 1965, 1976, 1980, 1983 



Race Former Smoker 



1965 1976 1980 1983 



All Females 
White Females 
Black Females 



8.2 


13.9 


15.7 


16.4 


8.5 


14.6 


16.3 


17.2 


5.9 


10.2 


11.8 


10.7 



Source: National Health Interview Surveys, 



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58 



TABLE 18 



Age-Adjusted (1970 U.S. Standard) Death Rates per 100,000 
Population for Lung Cancer in the United States, 1969-1981 



Year of 
Death White Males Black Males 



1969 55.55 63.68 

1970 57.39 65.54 

1971 59.11 66.70 

1972 60.86 73.35 

1973 61.58 74.76 

1974 63.16 78.10 

1975 64.16 79.29 

1976 65.69 81.56 

1977 66.82 87.34 

1978 68.18 88.31 

1979 68.76 89.22 

1980 70.03 92.70 

1981 69.86 94.93 

AAPC* 1.91 3.36 



*AAPC = average annual perc ent change from 1969 to 1981, 
Source: National Cancer Institute 



59 



TABLE 19 



Age-Adjusted (1970 U.S. Standard) Death Rates per 100,000 
Population for Lung Cancer in the United States, 1969-1981 



Year of 
Death 



White Females 



Black Females 



1969 
1970 
1971 
1972 
1973 
1974 
1975 
1976 
1977 
1978 
1979 
1980 
1981 

AAPC* 



10.30 
11.01 
11.94 
12.76 
13.28 
14.34 
15.27 
16.51 
17.37 
18.72 
19.46 
20.96 
21.69 

6.19 



10.56 
11.54 
12.50 
12.44 
13.53 
14.17 
14.80 
15.78 
17.25 
17.78 
19.11 
21.41 
21.74 

5.92 



*AAPC = average annual percent change from 1969 to 1981, 
Source: National Cancer Institute 



60 



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61 



TABLE 21 

Health Interview Survey 

Percent Current Smokers by Race and Sex 

1979 and 1980 



White 



Black 



Latino 



1979 



1980 



All 

Male 

Female 

All 

Male 

Female 



35.3 


37.7 


30.0 


38.7 


44.6 


38.3 


32.5 


32.7 


23.1 


34.5 


36.9 


31.0 


38.2 


45.0 


40.9 


31.4 


31.9 


22.9 



Source: Marcus and Crane (1983) 



62 



TABLE 22 



Los Angeles "Know Your Body" Smoking Data 



Have you smoked a whole cigarette? 

Girls 



Boys 

% N 

White 6.7 (371) 

Black 9.3 (257) 

Hispanic 13.1 (377) 



% N 

4.3 (343) 
3.0 (266) 

3.4 (376) 



lo you smoke 


cigarettes now? 


Boys 
% N 


Gir; 
% 


Is 
N 


0.8 (371) 


0.9 


(343) 


3.5 (237) 


1.1 


(266) 


3.3 (377) 


1.6 


(376) 



Source: Marcus and Crane (1983) 



63 



TABLE 23 



1979-1980 Health Interview Survey (Combined Samples) 
Number of Cigarettes Smoked Daily by Race/Ethnicity and Sex 



Male 



Female 



Cigarettes 














Daily 


White* 


Hispanic 


Black 


White* 


Hispanic 


Black 


Under 10 


16.9% 


53.1% 


45.7% 


27.4% 


60.8% 


58.7% 


11-20 


45.4 


31.4 


42.1 


47.5 


28.6 


31.9 


21-40 


32.2 


13.8 


10.7 


22.4 


9.4 


7.8 


over 41 


5.5 


1.7 


1.5 


2.7 


1.2 


1.7 



Source: 1979 and 1980 Health Interview Survey Public Use Tapes, distributed by 
the National Center for Health Statistics, National Institutes of 
Health, Hyattsville, Maryland. 

*Excludes persons of Latin American, Native American, and Asian ancestry. 



64 



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2. John, H.W. : Alcoholism and Criminal Homicide: A review. Alcohol Health 
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3. Estimate developed by Research Triangle Institute, North Carolina. 

4. New York City Police Department. Homicide Analysis, 1982. 

5. U.S. Department of Health and Human Services, Subcommittee Report on 
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6. U.S. Department of Health, Education, and Welfare, Alcohol and Alcoholism. 
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12. 


Ibid., p. 38 


13. 


Ibid. , p. 6 


14. 


Ibid., p. 6 



65 



15. Grant, B.F., Aitken, S. , "Reported Cirrhosis Mortality United States." In: 
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16. Herd, p. 6 

17. MMWR, pp 657-659 

18. National Cancer Institute, Cancer Statistics Review: Black, White, and 
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19. Herd, p. 10 

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21. Rachal , J.V. et al . , "Alcohol Abuse Among Adolescents." In: National 
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22. Herd, page 46 

23. Fourth Special Report, p. 24 

24. Herd, p. 10 

25. Taylor, P., Bell, P., "Alcoholism and Black Families: Cultural Barriers, 
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26. Fourth Special Report , page 87 

27. Ibid, p. 21 

28. Caetano, R. , Patterns and Problems of Drinking Among U.S. Hispanics . 
Prepared under contract for the Department of Health and Human Services 
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29. Herd, p. 41 

30. Caetano, p. 4 

31. Fourth Special Report , p. 86 

32. Caetano, p. 4 

33. Fourth Special Report , p. 87 



66 



34. Ibid, p. 24 

35. Ibid, p. 87 

36. Caetano, p. 26 

37. May, P. A., Alcohol and Drug Abuse Prevention Programs for American Indians: 
Needs and Opportunities . Prepared for the National Institute on Alcohol 
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Indians . 

38. National Institute on Alcohol Abuse and Alcoholism, "Facts in Brief: 
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39. Ibid. 



40. 


Ibid. 


41. 


Ibid. 


42. 


Ibid. 


43. 


Ibid. 



44. Alcohol and Drug Abuse Prevention Programs for American Indians , p. 3. 

45. May, P.A. : H3mibaugh, K.J. : Aase, J.M. ; "Epidemiology of Fetal Alcohol 
Syndrome Among American Indians of the Southwest." In: Social Biology , 
Vol. 30, No. 4, 1983: pp. 374-385. 

46. Alcohol and Drug Abuse Prevention Programs for American Indians , pp. 7-15. 
47 Fourth Special Report , p. 86. 

48. Ibid, p. 88 

49. U.S. Department of Health and Human Services, Fifth Special Report to the 
U.S. Congress on Alcohol and Health . DHHS Publication No. (ADM) 84-1291. 
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50. National Institute on Alcohol Abuse and Alcoholism, Alcohol and Health 
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420. 

51. Internal Report on Native Hawaiians, prepared by the Alcohol Epidemiology 
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Alcoholism, 1984. Based on Detailed Mortality Data Base maintained by the 
National Center for Health Statistics. 



67 



52. National Institute on Drug Abuse, Population Projections. 

53. Miller, J.D., Cisin, I.H., Gardner-Keaton, H. et . al . National Survery 
on Drug Abuse: Main findings 1982, Rockville, MD. : National Institute 
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54. Ibid. 

55. National Institute on Drug Abuse, Drug Abuse Among Minorities , Prepared 
for the DHHS Task Force on Black and Minority Health, unpublished, 

May 1985. 

56. Ibid. 

57. National Institute on Drug Abuse, Main findings for drug abuse treatment 
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58. CDC: Updates Acquired Immunodeficiency Syndrome (AIDS) United States, 
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59. Dicker, M.D., Vaughn, W.K. , Brodie, J.S., et.al. Seroepidemiology-of 
hepatitis B in Tennessee prisoners. J. Infectious Disease 1984; 150: 
450-9 and CDC: Delta-Hepatitis Massachusetts. MMWR 1984;33: 1666, 71. 

60. Mills, J., Drew, D. Serratia Marcescens endocarditis: A regional illness 
associated with intravenous drug abuse. Ann Intern Med 1976;84:29-35. 

61. Drug Abuse Among Minorities , Op. Cit. 

62. U.S. Bureau of Census. 1980 Census of Population. Standard Metropolitan 
Statistical Areas & Standard Consolidated Statistical Areas: 1980. 

PC 80-S1-5. Washington, D.C. : USGPO, issued October, 1981. 

63. Frank, B., et . al. Drug use among tenants of single room occupancy 
(S.R.O.) hotels in New York City. New York State Division of Substance 
Abuse Services: June, 1983. 

64. Main findings for drug abuse treatment units. Op. cit. 

65. Drug Abuse Among Minorities , Op. cit. 

66. Ibid. 

67. Adams, E.H. The epidemiology of cocaine abuse. Presented at the Regent 
Progress Symposium, Cocaine Abuse: Recognition & Treatment, Fair Oaks 
Hospital, Summit, New Jersey, May 8, 1982; and Adams E.H., Abuse/ 
availability trends of cocaine in the United States. Drug Surveillance 
Reports Vol. 1, No. 2. Rockville, MD: National Institute on Drug Abuse, 
1982. 



68 



68. DAWN, Medical Examiner Drug File. March 1985. and Personal Communication, 
National Institute on Drug Abuse, 1985. 

69. Drug Abuse Among Minorities , Op. cit. 

70. Ibid. 

71. Ibid. 

72. Ibid. 

73. Personal Communication, Op. cit. 

74. Shikar, R., Rice, T.W. , Zierdt, C.H., et. al . Outbreak of endocarditis 
caused by Pseudomonas aeruginosa, serotype Oil among pentazocine and 
tripel innamine abusers in Chicago. J. Infectious Diseases 1985; 151: 
203-8. 

75. Drug Abuse Among Minorities , Op. cit. 

76. Crime Analysis Unit, New York City Police Department. Homicide analysis. 
New York City, 1982. 

77. Cherubin, C, McCusker, J., Baden, M., et. al. The epidemiology of 
death in narcotic addicts. Am. J. Epidemiol, 1972; 96:11-22. 

78. Baden, M.M. Homicide, suicide, and accidental death among narcotic 
addicts. Human Pathology 1972; 31,91-95. 

79. Cherubin, C, Op. cit. 

80. Helpern, M. Fatalities from narcotic addiction in New York City: 
Incidence, circumstances, & pathologic findings. Human Pathology 
1972; 3:13-21. 

81. US Bureau of Census. 1970 Census of Population. Characteristics of the 
Population: Vol. 1, Part 34, New York, Section 1, Table 16. Washington, 
D.C.: USGPO, issued March 1973. 

82. Ruttenber, A. J. , Luke, J.L. Heroin-related deaths: new epidemiologic 
insights. Science 1984; 226-14-20. 

83. US Bureau of Census. 1980 Census of Population, Op. cit. 



69 



84. Frank, B., et . al . , Op. cit. 

85. Main findings for drug abuse treatment units, Op. cit. 

86. Drug Abuse Among Minorities , Op. cit. 

87. Padilla, E.R., Padilla, A.M., Morales A, et. al. Inhalant, marijuana, 
& alcohol abuse among barrio children and adolescents. Int. J. 
Addictions 1979; 14:945-64. 

88 . Drug Abuse Among Minorities , Op , cit. 

89. Ibid. 

90. Ibid. 

91. Ibid. 

92. Ibid. 

93. Ibid. 

94. Ibid. 

95. Ibid. 

96. Langston, J.W. , Ballard, P., Tetrud, J.W., et. al . Gironic parkinsonism 
in humans due to a product of meperidine-analog synthesis. Science 1983; 
219:979-80; and personal communication Paul Gorbe, Division of Chronic 
Disease, Center for Environmental Health, Center for Disease Control, 
1985. 

97. Crime Analysis Unit, Op. cit. 

98. Cherubin, C, et. al . Op. cit. 

99. Helpern, M. , Op. cit. 

100. Main findings for drug abuse treatment units. Op. cit. 

101. Drug Abuse Among Minorities , Op. cit. 

102. Ibid. 

103. Ibid. 

104. Ibid. 

105. Oetting, E.R. , Beavais, F., Edwards, R., et. al. Drug Abuse Among 
Native American Youth: Summary of Findings (1975-1981), Fort Collins CO: 
Western Behavioral Studies. 



70 



106. Ibid. 

107. Drug Abuse Among Minorities , Op. cit. 

108. Helpern, M. Op. cit. 

109. Surgeon General of the United States. The Health Consequences of Smoking: 
Cancer . Washington, D.C.: U.S. Government Printing Office, 1982. 

110. Surgeon General of the United States, The Health Consequences of Smoking: 
Cardiovascular Disease . Washington, D.C.: U.S. Government Printing 
Office, 1983. 

111. Surgeon General of the United States. The Health Consequences of Smoking: 
Chronic Obstructive Lung Disease . Washington, D.C.: U.S. Government 
Printing Office, 1984. 

112. National Center for Health Statistics, pre-publication information from 
Health, United States, 1985 , DHHS, July, 1985. 

113. Glynn, Thomas. Smoking-Related Cancers and the United States Black 
Population. National Cancer Institute, National Institute of Health, 
November, 1984. 



114. 


Ibid. 


115. 


Health, U.S., 1985. Op. cit 


116. 


Ibid. 


117. 


Darby, Jr., Charles. Smokin 




Females. Office of Smoking 


118. 


Ibid. 


119. 


Ibid. 


120. 


Ibid. 


121. 


Ibid. 


122. 


Ibid. 


123. 


Ibid. 


124. 


Ibid. 



71 



125. Ibid. 

126. Health, United States, 1985. Op. cit. 

127. Ibid. 

128. Darby. Op. Cit. 

129. Ibid. 

130. Ibid. 

131. American Cancer Society. Cancer Facts and Figures; 198A . New York: 
American Cancer Society, 1984. 

132. American Cancer Society. Cancer Facts and Figures for Black Americans: 
1983 . New York: American Cancer Society, 1983. 

133. National Cancer Institute. Cancer Incidence and Mortality in the U.S. 
1973-1977. Surveillance, Epidemiology and End Results (SEER) Program. 
National Cancer Institute, 1981. 

134. Silverberg, E. and Poindexter, C. Cancer Facts and Figures for Black 
Americans; 1979 . New York: American Cancer Society, 1979. 

135. White, J., Enterline, J., Alan, Z., and Moore, R. Cancer Among Blacks in 
the U.S.: Recognizing the Problem. In: C. Mettlin and G. Murphy (Eds.) 
Cancer Among Black Populations . New York: Alan R. Liss, 1981. 

136. Cancer Incidence and Mortality in the United States. 1973-1977 . Op. 
Cit. 

137. Glynn. Op. Cit. 

138. Ibid. 

139. Ibid. 

140. Department of Health and Human Services, Subcommittee Report on 
Cardiovascular Disease in Minorities. Task Force on Black and Minority 
Health, unpublished manuscript, February, 1985. 

141. Ibid. 

142. Brunswick, A.F., Messeri, P.S. Gender Differences in Processes of Smoking 
Initiation. Paper presented at the 1982 American Public Health 
Association meeting, Montreal, 1982. 



72 



143. Brunswick, A.F. and Messeri, P. A. Gender Differences in the Processes 
Leading to Cigarette Smoking. Journal of Phsychosocial Oncology , 1984, 2 
(1), 49-69. 

144. Hunter, S.M. , et a].. Social Learning Effects on Trial and Adoption of 
Cigarette Smoking in Children: The Bogalusa Heart Study. Preventive 
Medicine , 1982, U_, 29-42. 

145. American Cancer Society. A study of Smoking Behavior Among Black 
Americans . New York: Evaxx, Inc., 1983. 

146. Warnecke, R.B., et al . . Social and Psychological Correlates of Smoking 
Behavior Among Black Women. Journal of Health and Social Behavior 19: 
397-410, 1978. 

147. Glynn, T. Prevention and Cessation of Smoking and Cancer Risk Among 
Hispanic Americans. National Cancer Institute, Smoking, Tobacco, and 
Cancer Program, September, 1984. 

148. Marcus, A. and Crane, L. Smoking Behavior among U.S. Latinos: An 
Emerging Challenge for Public Health. American Journal of Public Health . 
February 1985, Volume 75, No. 2, 169-172. 

149. Glynn, Hispanic Americans. Op. cit. 

150. Marcus and Crane, Smoking Behavior among U.S. Latinos. Op. cit. 

151. Cardiovascular Subcommittee Report. Op. cit. 

152. Glynn, Hispanic Americans. Op. cit. 

153. Humble, Samet , Pathak, D. , Skipper, B. Cigarette Smoking and Lung Cancer 
in Hispanic Whites and Other Whites in New Mexico. American Journal of 
Public Health . February, 1985, Volume 15., No. 2. 

154. Marcus and Crane, Smoking Behavior among U.S. Latinos. Op. cit. 

155. Humble, et al.. Smoking and Lung Cancer in Hispanic Whites. Op. cit. 

156. Cancer Subcommittee Report. Op. cit. 

157. The Health Consequence of Smoking : Cancer. Op. cit. 

158. Cardiovascular Subcommittee Report. Op. cit. 

159. Ibid. 

160. Ibid. 



73 



161. Ibid. 

162. Ibid. 

163. Department of Health and Human Services, Subcommittee Report on Cancer in 
Minorities. Task Force on Black and Minority Health, unpublished 
manuscript, February, 1985. 

164. Ibid. 

165. Ibid. 

166. NIDA, Drug Abuse Among Minorities. Op. cit. 

167. Cardiovascular Subcommittee Report. Op. cit. 

168. Subcommittee Report on Cancer. Op. cit. 

169. Cardiovascular Subcommittee Report. Op. cit. 

170. Ibid. 



74 



Chemical 
Dependency 



A Review of Drinking 
Patterns and Alcohol 
Problems Among U.S. 
Blacks 



Denise Herd, M.A. 

Alcohol Research Group 

Institute of Epidemiology and Behavioral Medicine 
Medical Research Institute of San Francisco 
Berkeley California 



INTRODUCTION 
Historical Background; From Black Temperance to Alcoholization 1830-1930 

. . . being mercifully redeemed from human slavery, we do 
pledge ourselves never to be brought into the slavery of the 
bottle, therefore we will not drink the drunkard's drink: 
whiskey, gin, beer, nor rum nor anything that makes drunk 
come. (Temperance Tract for Freedman; cited in Cheagle, 
1969:29). 

Blacks of the early nineteenth century were characterized by strong support for 
the American temperance movement and unusually low rates of alcohol-related problems. 
The temperance movement had special appeal for blacks due to its close political 
connection with anti-slavery reform. Abstinence was regarded as a means of support 
for emancipation and equality. Blacks were inspired to develop a full-blown "Colored 
Temperance Movement" and to support temperance issues through the press and numerous 
religious and self-betterment organizations (Quarles, 1969; Cheagle, 1969; Herd, 
forthcoming c). 

After the Civil War and emancipation of slaves, blacks continued to promote 
temperance through the church, the "colored" women's club movement, and temperance 
societies such as the Women's Christian Temperance Union, the Sons of Temperance, 
Friends of Temperance, and Independent Order of Good Templars (Meir, 196^; Sellers, 
19if3; Lefler, I95i*). 

In the wake of their continued association with temperance reform, blacks 
exhibited comparatively low rates of drunkenness and problems due to drinking. John 
Koren's exhaustive analysis on the "Relations of the Negroes to the Liquor problem" 
(1899) concluded that chronic drunkenness was so rare among blacks that they were 
thought to be physiologically immune from prolonged inebriety. Making a similar point, 
Brinton (1891) argued that blacks were not as prone to acute alcoholism as whites due 
to the "inferior susceptibility (of the blacks') nervous system". These findings are 
supported by the 1880 U.S. mortality statistics which reported that for alcoholism "the 
proportion in those parts of the country in which the color distinction is made is much 
greater among whites than among the colored, the figures being for the Irish 6.7, for 
the Germans 2.7, for the whites 2.5 and for the colored 0.7 per 1,000 deaths from 
known causes. A large proportion of the deaths reported as due to alcoholism occur 
in connection with delirium tremens, and this form of disease is rare in the colored 
race (U.S. Census Office, 1880). 

By the early 20th century, black participation in the temperance movement had 
declined enormously. Southern prohibition had become blatantly racist and openly 
supported the policies of white supremacy including 3im Crow laws and black political 
disfranchisement (Herd, 1983). The press circulated a number of articles asserting that 
blacks were liquor crazed, violent, and sexually depraved (Herd, 1983). In response, 
most black leaders withdrew support from the prohibition movement and began to 
agitate for voting rights and black social equality. 

These shifts in the prohibition movement coincided with major demographic 
changes in the black population. Beginning around 1900, a massive wave of migration 
shifted large numbers of blacks from the rural south to the urban centers of the north 
(Gwinnell, 1928). In the cities to which blacks migrated ~ New York, Detroit, Chicago, 



77 



Cleveland — they quickly became a focus of the night-life and heavy drinking sub- 
cultures. Liquor flowed freely and blacks were closely identified with the illegal liquor 
traffic, both as small-time manufacturers and retailers, and heavy consumers. Blacks 
turned to bootlegging, operating speakeasies and throwing "liquor parties" as a means 
of economic support, especially during the depression years (Winston and Butler, [$1*3; 
Larkins, 1965). Blacks also became a prime market for illegal alcohol peddled by white 
rackateers (Drake and Cayton, [31*5', McKay, 1968). 

With the increasing urbanization and alcoholization of black communities, 
statistics on alcohol problems began to rise abruptly. An analysis from 1928 noted: 
From the year 1918 the death rate per 100,000 from 
alcoholism has steadily increased among Negro policy-holders. 
And since 1911, only one year, that of 1917 (a war year), 
was the rate higher than for the year 1927. In the past two 
years the rate increased from 'f.12 to 5.3, while the rate for 
white policy-holders declined from 3.1 to 1.8 per 100,000 
(Carter, 1928). 

Similarly, Malzberg {I9^t+) reported that black rates of hospital admissions for 
alcoholic psychoses in New York State between 1929-1931 greatly outstripped rates in 
the white population: 

Average annual standardized rates of first admissions with 
alcoholic psychosis were 22.2 per 100,000 Negroes and 6.5 
for the white population, the former being in excess in the 
ratio of 3.1* to 1, an excess of 2'fO percent (Malzberg, 19'f'f). 

The changes initiated during this period set the trend for subsequent decades as 
blacks became increasingly urbanized and alcohol use gained a major foothold in social 
and economic life. 

Indicators oi Alcohol Problems Among Contemporary U^. Blacks 

The following review examines black drinking patterns and alcohol-related 
problems as they emerged since the Repeal Era. The focus of the review is on changes 
in indicators of alcohol problems among blacks from roughly the 1950's through the 
1980's. 

The review will examine both medical and psycho-social indicators of alcohol 
problems in the U.S. black population. Chronic diseases (such as liver cirrhosis and 
esophageal cancer) will be the primary focus of the discussion on medical consequences. 
The review of psycho-social indicators will focus on two major areas: (1) statistics of 
alcohol treatment and alcohol-related arrests from official records; and (2) information 
on social problems related to alcohol use at the personal, familicd, and community level 
gathered from survey data. 

The various types of alcohol-related problems represented in these indicators 
may involve different patterns of alcohol consumption and interaction with different 
sets of normative values and social conditions. Acute medical consequences such as 
alcohol overdoses or drownings are often related to "binge drinking" or rapid, high 
quantity alcohol consumption in combination with hazardous environmental conditions. 
In contrast, physiological diseases like liver cirrhosis are principally the result of heavy 
long-term alcohol consumption, whether or not it is accompanied by overt intoxication 
or untoward social consequences. 



78 



Psycho-social indicators of alcohol problems are affected not only by drinking 
patterns but also by prevailing norms and attitudes towards the effects of alcohol both 
at the family and at the broader community level. Hence, personal and family problems 
attributed to drinking, such as divorce and job troubles, may be directly influenced by 
social expectations around drinking (e.g., tolerance for drunkenness) held by one's family 
and friends. Rates based on official statistics such as arrests for public drunkenness 
or drunk driving are often affected by law enforcement practices and legal norms. 
Similarly, treatment statistics for alcohol problems reflect familial and community 
norms, as well as institutionalization practices within the society. 

Black drinking patterns will be analyzed to determine how patterns of alcohol 
consumption (e.g., quantity and frequency) and normative values toward alcohol use 
may affect rates of alcohol problems. Variations in drinking patterns among gender, 
class, age, regional and religious groups within the black population will be examined 
to ascertain which groups are at highest risk for alcohol-related problems. 

Through the analysis of alcohol problem indicators and drinking patterns, key 
problem areas and vulnerable population sub-groups will be identified. Specific strategies 
for problem intervention and prevention will then be discussed. 



79 



ALCOHOL-RELATED MEDICAL PROBLEMS 

Liver Cirrhosis 

Prior to the early 1950's, age-adjusted rates of liver cirrhosis mortalityi in the 
non-white population2 were generally lower than rates in the white population. This 
trend rapidly changed after 1955. In the ten year span between 1960 and 1970, the 
cirrhosis mortality rate of the non-white population doubled, increasing from 11.9 to 
23.8 deaths per 100,000 persons. For the entire period between 1950 and 1973, non- 
white rates increased 2'f2% while rates among whites rose only 60%. 

Since 1973, cirrhosis rates in both races have declined slightly, but rates among 
black Americans are still disproportionately high (Herd, forthcoming b). According to 
a recent report (De Luca, 1981), non-white males in the 25-3^* year age bracket who 
reside in seven major cities are ten times more likely to die of liver cirrhosis than 
whites. Andfor all ages, the cirrhosis mortality rate for blacks is almost twice as high 
as the rate for whites. In 1979, age-adjusted cirrhosis rates for non-whites were 21.1 
per 100,000 population as compared to 11.1 per 100,000 persons for whites. 



1. Mortality rates are based on data from death certificates and population data 
collected by the U.S. Census. It is well known that both of these data sources are 
biased in recording information for non-whites. However a combined number of factors 
suggest that the time trend data we are looking at says something "real" about changes 
in the relative incidence of mortality between the races. First, several studies suggest 
that in general, physicians' practices of recording cirrhosis deaths on death certificates 
have remained stable over time (Speizer et al., 1977; Kramer et al., 1968). Second, 
census coverage of the non-white population has improved substantially in the Icist 
several decades (Siegel, 1974); so that black rates have been increasing disproportionately 
even while the population base has been growing. Third, the increase in mortality is 
not sporadic, but is highly patterned by geographical region, occurring primarily in areas 
that have had consistently accurate reporting of cirrhosis for several decades. Finally, 
clinical and epidemiological studies indicate that increasing numbers of blacks are 
experiencing chronic diseases related to long term heavy alcohol consumption (Ernster 
et al., 1979; Pottern et al., 1981; Rogers et al., 1982) 

2. Cirrhosis statistics used in this analysis are based on the "non-white" classification 
used to designate racial groups other than Caucasians in U.S. mortality reports and 
population tables. "Non-white" rates provide a rough estimation of black cirrhosis 
mortality since blacks accounted for about 92% of the U.S. non-white population during 
most of the years covered by this analysis (MacMahon and Pugh, 1970). In the analysis 
of cirrhosis rates by selected geographical regions, regions with large non-black minorities 
such as the Pacific and Mountain areas, are excluded to provide a more accurate 
portrait of trends in black rates. 



80 



FIGURE 1 



Age Adjusted Death Rates 

For Cirrhosis of the Liver 

By Color. 1935-1978 




Legend 

NonwhHa 



Whit* 



1933 1940 1945 1950 1955 1960 1965 1970 1975 1980 

Y«ar 

Figure 1: Rates reported per 100,000 population. 

Source: Herd (forthcoming, b) 



81 



nCSURE 2 



100 



o 
o 
o 

o 

o 

« 

Q. 



o 
« 



Age Adjusted Death Rates 

For Cirrhosis of the Liver 

By Color and Sex. 1935-1978 




-i«i-^ ■,-.r.s .,.,r\^*.r:r->,/. 



,Ai 



Legend 

Nonwhite Men 

Nonwhite Women 

■■■■■■■■■■■■■■■ 

White Men 
White Women 



1 
1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 

Year 



Figure 2: Rates reported per 100,000 population. 

Source: Herd (forthcoining, b) 



82 



J 



Sex Differences in Cirrhosis Rates 

The recent increase in non-white age-adjusted cirrhosis mortality rates has been 
equally dramatic for non-white males and females. Between 1950 and 1973 the increase 
in mortality for non-white males was 276% versus 66% for white males. Over the 
same period, cirrhosis rates for non-white females increased 205% as compared to 54% 
for white females. 

Age-Specific Mortality Rates 

In recent years, a greater proportion of non-whites died at younger ages of 
cirrhosis than whites. In 1975, cirrhosis deaths for non-white men reached their peak 
at ages 55-6^^, while mortality for white males peaked in the 65-7^^ year age group. 
On the whole, women exhibited higher cirrhosis rates at younger ages than men, but 
again non-white womens' rates peaked at earlier ages than rates for whites. The 
highest rate of cirrhosis occurred in the ^^5-5l^■ age range for non-white women compared 
to 55-64 for white women. 

In the older age groups, non-whites exhibited lower cirrhosis death rates than 
whites. From 65 years old onward, white men appear at considerably greater risk of 
dying of cirrhosis than non-whites. For women, non-whites over 75 are less likely to 
die of cirrhosis than whites. 

Cohort Effects 

The contemporary age distribution of cirrhosis mortality in both races is shaped 
to a large extent by cohort effects in the wake of National Prohibition and Repeal. 
Persons maturing during the turn-of-the-century temperance and prohibition movement 
exhibited lower mortality rates than cohorts which came of age before or after this 
time. Hence the cirrhosis mortality rates of each successive cohort born from 1865 
through 1895 was lower than the previous one.This trend began to reverse in cohorts 
born after 1900, and their mortality rates increased sharply. Cohorts of 1920 and 1930 
showed particularly high increases. Recent studies suggest that this upward trend is 
slowing based on the minimal increases and even slight drop in mortality experienced 
by the cohorts born between 1935-1944. 

Cohort effects are more dramatic for non-whites than whites. Blacks born during 
the 19th century and through about 1904 exhibited lower cirrhosis mortality rates than 
whites. By the cohort of 1910, which came of age in the 1920's and 1930's, this pattern 
shifted and non-white death rates began to outstrip white death rates. With each 
successive cohort, the mortality level of non-white groups further surpassed the white 
population contributing to the current excess of mortality among non-whites. 

The lower current rate of cirrhosis mortality among older non-whites is a 
reflection of these historical changes. The black elderly are members of cohorts born 
prior to 1910, which have been characterized by lower cirrhosis rates throughout their 
Ufe-span. 



83 



FIGURE 3 



Age Specific Death Rates from Liver Cirrhosis 

White and Nonwhite 10 Year Age Groups 

1935 and 1975 



70 n 




Legend 

1935 WhHes 
1935 Nonwhites 

i^^^M li^BaM ^mm^ m 

1975 Whites 
1975 Nonwhites 



75-84 



Age at Death 
Figure 3: Rates reported per 100,000 population. 



Source: Herd (forthcoming, b) 



84 



I 




'00i> J«d sgiBaQ 



Q) 




in 


O) 






< 




□ 


>» 






i3 






</) (/} 


o 






lO 




</) w- 


O) 




o o 


r- 




^ x: 


1 




ir o 






m 




O^ 


00 




x: 








* 




<u »- 


Ui 




> m 


<D 




-' a> 


CO 




s for 

Whit 


CO 
•a 




0) ^ 


■«-• 




DC 


c 




D 




^ 






■«— ■ 






CO 






0) 






Q 








85 



MO'OOl ''^(^ 8g)e»a 



Regional Differences 

Between 1914-9 and 1970, the pattern of increase in non-white cirrhosis mortality 
rates varied greatly by geographical region. Age-adjusted rates rose to dramatic 
proportions in the Mid-Atlantic, East North Central and the South Atlantic regions, 
while in the South Central regions they remained low. Thus in 1971, blacks in the 
North and Coastal South were from 2 to 'f times more likely to die of cirrhosis than 
blacks in the Deep South. 

The geographical pattern of changes in the non-white population differs in 
important ways from the pattern observed for whites. Whereas black rates escalated 
dramatically in the Middle Atlantic and East North Central regions, they only increased 
slightly for whites. Mortality rates for whites rose more in the interior south than 
they did in the urban north. Among blacks, cirrhosis rates in the interior south were 
among the most stable and showed only modest increases between the 1950's and 1971. 
This differential pattern of change suggests that elevated rates among blacks in the 
north may be related to the migratory influx and increasing urbanization of the black 
population in these areas. 

However, the South Atlantic region witnessed the greatest relative increase in 
cirrhosis mortality among both blacks and whites. The low rates in this region in 19'f9 
which were similar to rates in the deep South, rose to nearly the same level as rates in 
the East North Central region by 1971. The escalation of both white and non-white 
cirrhosis mortality in this area might be caused by the increasing urbanization and 
liberalization of attitudes towards alcohol use which have occurred in these regions 
since the 1950's. 



86 



TABLE 1 

CIRRHOSIS MORTALITY 

Age-Adjusted Rates 

Selected Regions: White/Non-White 

19*9 - 1971 



19*9 - 


1951 


1959 - 


1961 


1969 - 


1971 


% 


Change 


White 


Non- 
Whites 


White 


Non- 
Whites 


White 


Non- 
Whites 


W 


N 


10.5 


11.7 


12.2 


22.7 


15.33 


40.18 


46% 


243% 


8.7 


9.1 


10.11 


12.13 


12.8 


25.6 


47% 


181% 


7.6 


5.7 


8.5 


8.6 


12.6 


21.2 


66% 


272% 


6.0 


4.9 


5.8 


5.6 


8.2 


8.9 


37% 


67% 


6.7 


5.3 


lA 


6.8 


10.8 


10.9 


62% 


105% 



Middle Atlantic 

East North Central 

South Atleintic 

East South Central 

West South Central 6.7 



Source: U.S. Bureau of the Census and National Center for Health Statitistics 



87 



FIGURE 6 



Age Adjusted Regional Cirrhosis Rate 
By Color. 1959-1971 



45 n 



-40 



35 



30- 



O 
O 
O 

O 25 



V 

a. 



o 
t) 

Q 



20- 



15 



10 




1949-1951 1959-1961 

Figure 6 Rates reported per 100,000 population. 



iddle Atlantic 



East North Central 



South Atlantic 



Middle Atlantic 

East North Central 
South Atlantic 
.West South Central 

East South Central 

LEGEND: 

Whites 

Nonwhites 



1969-1971 



Source: Herd (forthcoming, b) 



88 



Etiological Factors in Elevated Non-White Cirrhosis Mortality Rates 

The problem of increasing non-white cirrhosis mortality is complex and seems 
to represent the interaction of several possible factors. First, recent studies show 
higher proportions of morbidity and mortality from acute liver diseases ~ fatty liver 
and alcoholic hepatitis ~ among non-whites (Garagliano et al., 1979; Kuller et al., 1969) 
The excess in fatty liver and hepatitis occurs primarily in young adult males. Alcohol 
consumption is specified as the primary etiological agent for acute liver disease in 
these studies, although it is possible that other factors such as the elevated rate of 
hepatitis B virus among non-whites (Alter, 1983) could increase disease susceptibility 
(Hislop et al., 1981; Mills et al., 1979). 

High rates of mortality from fatty liver and hepatitis probably contribute 
significantly to the steep increase in reported cases of liver cirrhosis deaths among 
young black males, given that true cirrhosis is rare in youthful populations. However, 
the increasing rates of acute liver disease among black males cannot account for the 
general increase in liver cirrhosis mortality among non-whites since it is the high rates 
of mortality in middle-aged and older adults which contribute the most to overall death 
rates. 

The high prevalence of mortality in the older age groups undoubted reflects the 
importance of a major factor in cirrhosis etiology ~ lengthy duration of heavy alcohol 
consumption. Clinical research by Lelbach (1975) indicates that the risk for cirrhosis 
is directly influenced by the number of years of heavy drinking. From a similar 
perspective, using aggregate statistical data, Skog (1980) points out that mortality 
outcome represents the cumulative effects of previous and current alcohol consumption 
level. 

The importance of duration of heavy consumption may provide insight into the 
disparity between white and non-white cirrhosis mortality despite the similar rates of 
heavy drinking reported for blacks and whites in most surveys (Cahalan et al., 1969; 
Clark et al., 1982). A recent study by Caetano (198^*) suggests that there may be 
differences in the stability of heavy drinking over the life span among black and white 
males. His analysis showed that for white men, frequent heavy drinking is most 
prevalent in young adults, but rapidly falls off as they reach their 30's. In contrast, 
among blacks, frequent heavy drinking is more common in men over 30, suggesting that 
it is a stable pattern of mid-life. If so, this would increase the numbers of drinkers in 
the black population at risk for cirrhosis ~ despite the similarity in proportions of 
heavy drinkers in the two groups at a single point in time. 

While provocative, Caetano's research leaves a major question unanswered. The 
differences in the age structure of heavy drinking described for the two groups could 
reflect either differences in the onset and socialization of drinking among contemporary 
blacks and whites, or they could stem from historical differences, resulting in "cohort 
effects" which predispose blacks over 30 to heavy drinking. 

A recent analysis by Herd (forthcoming b) focussed on the importance of historical 
changes in black drinking patterns in explaining the dramatic "cohort effects" in black 
cirrhosis mortality. This work suggests that black attitudes towards alcohol use rapidly 
transformed from traditional abstinence values held throughout the 19th century to a 
focus on heavy drinking lifestyles in the 1920's and 1930's. The period coincided with 
great waves of black northern migration to urban areas. These social changes, along 
with continuing urbanization, appear to have led to increasing alcoholization of the 
black community, making blacks more vulnerable to cirrhosis in the context of the 
general expansion of alcohol and drug use in American society in the 1960's and 1970's. 



89 



Esophageal Cancer 

Incidence 

The reported incidence of esophageal cancer among blacks is extraordinarily high. 
Between 1969-71, black males in the 35-^^^ age group had an incidence rate 10 times 
that of whites. Among the older age group where the disease predominates, the rate 
among black males is still almost fourfold that of whites. Although females of both 
races experience much lower rates of the disease, the gap between white and black 
women looms large. The rates among black women are from 3 to 7 times higher than 
whites. 

Table: 2 Esophagael Cancer Annual Incidence Rates per 100,000 Population 
(Third National Cancer Survey 1969-71, Ernster, et al., 1979) 



Males 


White 


Black 


35-ttit 


0.5 


5.3 


^5-51^ 


^.2 


30.7 


55-6^ 


14.9 
Females 


58.8 


35-1*1* 


0.4 


2.7 


^5-51* 


1.2 


9.0 


55-GH 


4.6 


13.9 



Time Trends/Regional Differences 

Trends in mortality due to cancer of the esophagus share many similarities with 
the patterns observed in cirrhosis rates. In a cohort analysis of mortality during the 
period 1930-67 (Schoenberg et al., 1971), the non-white population experienced steadily 
and rapidly rising rates, while those of the white population remained relatively stable. 
The rising non-white mortality occurred at all ages and in all areas of the country and 
was more pronounced among males than females. When mortality rates were analyzed 
by U.S. geographical divisions for 1940-66, the highest rates for each race and sex were 
in the Northeast and the lowest were in the South. The geographical differential was 
more prominent for non-whites (threefold) than for whites (twofold). Over time, the 
non-white population showed increasing rates in all divisions, but the most rapid increase 
has been in the South. 

A correlation analysis of mortality from 1950-66 on urbanization, cigarette and 
alcohol sales in 41 states in 1960 revealed that urbanization was the strongest predictor 
of mortality rates. It was concluded that migration may be a significant factor in the 
pattern of cancer deaths since "the rising mortality from esophageal cancer among non- 
whites has paralleled the increasing proportion of non-whites living in urban areas" 
(Schoenberg et al., 1971). 

More recent case control studies argue that alcohol consumption may be a primary 
etiological agent in the development of this tumor among blacks. Pottern et al. (1981) 
showed that the age-adjusted death rate for esophageal cancer in Washington, D.C. for 
non-white males in 1970-75 was 28.6/100,000, far higher than the national rate of 
12.4/100,000 and rates in other metropolitan areas. This study concluded that the 
major factor responsible for the excess in esophageal cancer death rates was alcoholic 



90 



beverage consumption, with an estimated 81% of the esophageal cancers attributed to 
its use. The relative risk (RR) of esophageal cancer associated with use of alcoholic 
beverages was 6A (95% confidence interval: between 2.5 and I6.ii. The relative risk 
increased with amount of ethanol consumed and was highest among drinkers of hard 
liquor, although the risk was also elevated among consumers of wine and/or beer only. 
By contrast, the high risk associated with cigarette smoking was 1.9 (1.0, 3.5) when 
controls with smoking-related causes of death were excluded, but declined to 1.5 (0.7, 
3.0) when adjusted for ethanol consumption. It was noted that "the per capita 'apparent 
consumption' of alcoholic beverages on the basis of revenues for the District of Columbia 
surpasses the national level by nearly fourfold for hard liquor and about threefold for 
wine, although part of the excess is related to purchases by non-residents." 

Rogers et al., (1982) study of the increasing frequency of esophageal cancer 
among black male veterans in Baltimore also emphasized the role of alcohol as a major 
etiological factor. Heavy alcohol intake occurred more frequently in esophageal cancer 
patients than in control patients and many of these patients experienced multiple 
alcohol-related complications. 



91 



ALCOHOL-RELATED HOSPITALIZATION AND TREATMENT 
Psychiatric Treatment 

Since the 1930's blacks in the urban north have been characterized by 
disproportionately high rates of psychiatric admissions for alcohol-related diagnoses 
(Malzberg iSi^ii, 1960). The excess in black rates for alcoholic psychoses in New York 
in the 1930's and 1940's was attributed to high rates of urban migration, low social 
and economic status, and high rates of disease and social problems (Malzberg 19'f't). 
Between 19'tO and 1950, black rates of hospital admissions for alcoholic psychoses in 
New York declined considerably, although they were still in excess of rates among 
whites. The decline in rates was attributed to an overall improvement in the socicQ 
and health status of New York blacks. 

However, by the i960's blacks were still greatly over represented in psychiatric 
admissions for alcohol-related diagnoses in some states. In a study of 3,339 first 
admissions to Ohio State public mental hospitals from 3uly 1958-December 1961 (Locke 
and Duvall, 196^*), the rate for non-white males residing in metropolitan areas was 
more than double that of metropolitan whites (61.6 per 100,000 population as compared 
to 2't.2 per 100,000 population). In a similar study of Maryland hospitals over a three 
year period ending in 196^ (Gorowitz et al., 1970) the rate for black men was 
approximately 1 1/2 times the rate for white men (656 per 100,000 population compared 
to 433 per 100,000 population). Among females there was an even greater gap between 
blacks and whites: the rate for black women was twice as great as the rate for white 
women (219 per versus 99 per 100,000 population). 

Rosenblatt's analysis (1971) of admissions for treatment of alcohol-withdrawal 
symptoms in a psychiatric hospital in Brooklyn, New York revealed that black admissions 
were from 3.5 to 12 times higher than whites depending on zone of residence. The 
following socio-demographic factors were significantly correlated with the rate of 
admissions in a zone — overcrowded housing, high rates of aid to dependent children, 
venereal disease, juvenile delinquency, tuberculosis, unemployment, homicide, and low 
educational level, median income and residential stability. 

A nationwide survey (Meyer, 197^*) of admissions to state and county mental 
hospitals in 1972 also showed that admissions for alcohol disorders were higher for non- 
whites (69.6 per 100,000 population) than whites (50.3 per 100,000 population). However, 
the same survey reported that the proportion of alcohol-related diagnoses (with respect 
to all psychiatric conditions) for non-whites was slightly lower than that for whites, 
22.7% versus 27.3%. 

The latter finding was repeated in an analysis of mental hospital admissions for 
1975. Blacks in state and county mental hospitals were more likely to be diagnosed 
as having schizophrenia, while whites and Hispanics were more often designated as 
having alcohol and drug disorders and depression. In other types of mental health 
facilities, the proportion of black admissions for alcohol and drug problems was lower 
than or similar to that for whites, except in outpatient psychiatric and private general 
hospitals, for which the percentage for blacks was considerably higher than for whites 
(American Public Health Association 1975). 

In general it appears that the disparity between black and white psychiatric 
admissions and institutionalization for alcohol-related disorders may have decreased by 
the middle 1970's. However, it is difficult to document this hypothesis given the lack 
of consistent trend data on blacks at the regional and national level. Further analysis 



92 



on the change in population rates for psychiatric disorders and on the change in the 
proportion of black alcohol-related diagnoses relative to other psychiatric disorders over 
time is needed before any firm conclusions can be drawn. 

Treatment in Alcohol-Specific Agencies 

While publicly financed alcohol treatment agencies were set up in many states 
in the 1950s and 1960s, the early 1970's witnessed the establishment of the National 
Institute on Alcoholism and Alcohol Abuse (NIAAA) and the development of a wide 
range of alcohol-specific treatment agencies across the country. These agencies now 
constitute the primary institutional base for handling alcohol-related problems. 

Recent large-scale surveys of alcohol and drug-specific treatment agencies show 
that disproportionate numbers of blacks are being seen in alcohol treatment programs. 
One of the earliest evaluations of forty-four NIAAA funded Alcoholism Treatment 
Centers and five special population programs, showed greater percentages of black 
clients than would be expected in all program types (Towle, 197^^). They were 
overrepresented in the Alcohol Treatment Centers by about ^+0% and only slightly 
overrepresented in the employee-based industrial alcohol programs (lAC's). However 
in the public inebriate and drinking driver programs, the proportion of blacks in treatment 
was 200-300% greater than than their proportion in the U.S. population. 

A survey of alcohol treatment programs for 1977-1980 (NIAAA, 1982) showed 
that blacks constituted about 18% of the client population although they only comprised 
roughly 11% of the U.S. population. Similarly, surveys which included both alcohol and 
combined alcohol and drug treatment programs reported that for 1980 and 1982, blacks 
comprised 15% of the treatment population (NIAAA, 1980, 1983). In 1982, over itk,000 
blacks were seen in alcohol or combined alcohol and drug treatment programs. Population 
rates were over 50 percent higher for blacks than whites, or 159.58 versus 101.15 per 
100,000 population. 



93 



Table 3: Percentage of Black Clients Receiving Treatment for Alcoholism, 

Selected States, 1980-1982 



1980 



1982 













% Blacks 












in State 


State 


All Clients 


% Blacks 


All Clients 


% Blacks 


Population 


Alabama 


2,'tll 


33.8 


1,632 


28.2 


25.6 


Arkansas 


3,336 


24.2 


1,750 


26.2 


16.3 


California 


65,853 


8.0 


37,542 


11.11 


7.7 


Connecticut 


'fjOOO 


15.4 


3,185 


19.0 


7.0 


Delaware 


if61 


22.3 


650 


16.6 


16.6 


Florida 


8,998 


15.8 


11,008 


15.8 


13.8 


Georgia 


6,656 


28.6 


4,964 


26.8 


26.8 


Illinois 


8,115 


16.0 


8,722 


22.2 


14.6 


Indiana 


6,169 


14.2 


4,601 


11.2 


7.6 


Kansas 


2,635 


8.4 


2,878 


7.4 


5.3 


Kentucky 


tt,2i^il- 


13.2 


2,378 


7.8 


7.1 


Louisiana 


i^,089 


35.9 


6,088 


37.8 


29.4 


Maryland 


7,867 


33.9 


9,098 


31.2 


22.7 


Massachusetts 


11,^22 


9.4 


15,905 


6.9 


3.8 


Michigan 


11,992 


15.2 


10,814 


16.4 


12.9 


Mississippi 


2,260 


28.4 


2,291 


33.6 


35.8 


Missouri 


^,173 


21.1 


2,088 


14.8 


10.4 


New Jersey 


3,945 


22.8 


6,675 


23.6 


12.6 


New York 


22,'f04 


28.8 


24,332 


29.7 


13.7 


North Carolina 


7,990 


27.8 


7,070 


27.7 


22.4 


Ohio 


8,iH9 


13.4 


9,649 


14.1 


10.0 


Oklahoma 


^^,573 


10.0 


2,845 


16.8 


6.8 


Pennsylvania 


7,742 


20.9 


6,499 


26.5 


8.8 


South Carolina 


3,629 


31.5 


3,237 


27.9 


30.4 


Tennessee 


4,426 


18.3 


2,894 


16.5 


15.8 


Texas 


11,617 


19.2 


8,100 


13.0 


12.0 


Virginia 


8,804 


22.6 


6,390 


24.6 


18.9 


Washington 


6,980 


6.2 


8,823 


5.6 


2.3 


West Virginia 


1,481 


8.8 


1,814 


8.4 


3.0 


Washington, D.C. 


2,244 


79.0 


2,708 


87.0 


70.3 


NATIONAL 












TOTALS 


318,633 


1*^.* 


283,166 


15.6 


11.7 


(52 states 












inclusive) 













Source: 1980 and 1983 National Drug and Alcoholism Treatment Utilization Surveys, 
U.S. Department of Health and Human Services, Public Health Services. 

Statistical Abstract of the United States, 1982-1983. 



94 



Table *: Alcohol Client Treatment Admissions Data for Blacks, Fiscal Year 1983 









% Blacks 








in 


State 


AU Clients 


% Blacks 


State 


Alabama 


6,883 


22.6 


25.6 


Arkansas 


^^,077 


16.5 


16.3 


California 


33,696 


4.3 


7.7 


Connecticut 


11,836 


13.5 


7.0 


Delaware 


5,073 


26.7 


16.6 


District of Columbia 


5,681 


70.0 


70.3 


Florida 


51,531 


12.6 


13.8 


Georgia 


26,66't 


25.^^ 


26.8 


Illinois 


56,923 


18.'f 


14.6 


Kansas 


li^,9ii3 


7.1^ 


5.3 


Maryland 


23,5m- 


27.3 


22.7 


Massachusetts 


6^,^*22 


7.1 


3.8 


Michigan 


32,039 


18.0 


12.9 


Mississippi 


6,^^10 


29.1 


35.8 


Missouri 


1M39 


15.0 


10.4 


New Jersey 


15,36^* 


28.5 


12.6 


New York 


11^^,182 


27.8 


13.7 


North Carolina 


25,8^^3 


25.2 


22.4 


Ohio 


18,779 


17.7 


10.0 


Pennsylvania 


if 1,660 


28.3 


8.8 


South Carolina 


18,^59 


li^A 


30.4 


Tennessee 


^,990 


13.8 


15.8 


Virginia 


39,^^60 


25.2 


18.9 


Washington 


92,318 


3.6 


2.3 


West Virginia 


5,290 


It 


3.0 


TOTALS 


92*,630 


15.0 






(38 states) 


(38 states) 





Source: State Resources and Services Related to Alcohol and Drug Abuse Problems: 
An Analysis of State Alcoholism and Drug Abuse Profile Data, National 
Association of State Alcohol and Drug Abuse Directors, Inc. Washington, D.C. 

Statistical Abstract of the United States, 1982-1983. 



95 



An analysis of the prevalence of blacks in alcohol treatment facilities by states 
for 1980 and 1982 showed important regional differnces in patterns of utilization (NIAAA, 
1980, 1983). In some of the large, densely populated states in the Northeastern Seaboard 
area, the proportion of blacks in treatment was 2-3 times higher than the proportion 
of blacks in the states' populations. Blacks were moderately overrepresented in 
treatment agencies in the Mid-West, the West, and a few southern states. However, 
in the interior South, the percentage of blacks in treatment was very similar to their 
proportion in the population. 

A similar pattern of regional differences in admissions to alcohol treatment units 
was described in a 1983 survey of state alcohol and drug programs (National Association 
of State Alcohol and Drug Abuse Directors, 198^^) and is depicted in chart 7. 

Age Distribution of Blacks in Alcoholism Treatment Settings 

A number of studies in different treatment settings have reported that b'acks 
in alcohol treatment are considerably younger than whites. 

An analysis of the characteristics of 2831 alcoholics admitted into Maryland 
psychiatric facilities from 3une 1963 to 3uly 1964 showed that the median age of non- 
white men and women was 38 years, while comparable ages for white men and women 
were ^^6 and 'f't years, respectively (Gorowitz et al., 1970). Two years later a study in 
the same facility revealed that among non-white men and women the highest rates of 
admission with alcohol-related diagnoses were in those aged 35 to ^t^ years, while among 
white men and women peak rates occurred in persons between i+5 and 54 years of age 
(Gorowitz et al., 1970). 

Similar patterns are reported in a series of studies on characteristics of patients 
hospitalized for acute alcoholic psychoses in New York. Gross et al. (1963) reported 
that for a sample of 147 male patients, blacks had a mean age that was 8 years 
younger than whites. In a later study of 567 men (Gross et al., 1972) blacks were also 
found to be approximately 8 years younger than whites. There were twice as many 
black patients in the 20-34 age group; yet, in the oldest age groups, there were nearly 
three times as many white, as black patients. It was suggested that black patients 
probably develop alcoholism in response to the problems of late adolescence and early 
adulthood, while white men appear to resort to heavy drinking and develop alcoholism 
in reaction to the problems of middle age. 

An analysis of clinical records of 1400 men (Gross et al., 1971) reported that 
blacks experienced hallucinations more often and at younger ages than whites. Among 
blacks the largest percentage of hallucinations was in the age group 25-34 (39%) while 
among whites the highest percentage was in the age group 35-44 (62%). 

A survey by Zax et al., (1967) of alcoholics in a variety of agencies (Salvation 
Army, criminal justice system, hospitals, and psychiatric facilities) in Monroe County, 
New York showed a strong overrepresentation of non-white males and females in the 
younger age groups. Seventy-four percent of the non-white men and 80% of the non- 
white women with a primary diagnosis of alcoholism were under 50 years of age, 
compared with 47% and 64% of white men and women respectively. The authors 
suggested that the relative youthfulness of non-whites in alcohol treatment may be 
attributed to the following factors: (1) the excessive use of alcohol is probably a 
relatively new problem for nonwhites; (2) non-whites who use alcohol excessively have 
a shorter life-span; or (3) the non-white population of the locale under study is expanding 
very rapidly by reason of both a high birth rate and the inward migration of young people. 



96 



Studies of treatment facilities in Missouri showed the same pattern. In an 
analysis of psychiatric admissions for alcoholism in Kansas City at both public and 
private facilities, it was observed that considerably more blacks (70%) than whites 
(^^6%) were under ^5 years of age when admitted for treatment (Hornstra and Udell, 1973). 

Similar findings were reported for a study of 100 black and 100 white male 
alcoholics at another treatment facility in St. Louis (Viamontes and Powell, 197^^). The 
mean age for blacks in the facility was 37 years and for whites it was ^6. In general, 
blacks had started drinking earlier, and lost control sooner than the white patients. 
Blacks began drinking at about age I5K2 years, compared to 19 years for whites. 
Unmanageability of drinking problems began, on the average, at age 28 for blacks and 
age 33 for whites. It was suggested that blacks may enter treatment earlier because 
of lack of family support, since a greater proportion are unmarried or divorced. 

Locke and Duvall (196^^) reported on alcoholic first admissions for Ohio state 
mental hospitals in 1960. Among the major findings, they focused on the prominent 
age differences between black and white admissions: 

It is particularly noteworthy that among nonwhites 69% of 
the alcoholic first admissions were under ii-5 years of age, 
whereas only ^9% of the while alcoholic admissions were 
under this age. Among whites, the peak ages of admission 
were 't5-'f9, followed closely by the i+O-i^i^ and 50-5^ age 
groups. Among nonwhites, the peak ages were W-^^, Among 
metropolitan males the non-white:white ratios ranged from 
^.^•A at ages 25-29 to 2.1:1 at ages 60-6't. . . .The marginal 
economic status of non-whites, possibly involving a lower 
nutritional level, may produce an earlier advent of the 
psychophysiological effects of alcohol. The earlier entrance 
of non-whites into the "working world" (non-whites generally 
have less years of schooling), the fact more than three-fourths 
of the non-whites aged 25-6^* are out-of-state migrants, and 
that a greater percentage of the non-white females are in 
the labor force, would limit the availability of a custodial 
relative, thus militating against the retention in the home of 
the non-white alcoholic (p. 525). 



97 



BLACKS, ALCOHOL CONSUMPTION AND TRAFFIC ACCIDENTS 

There are a limited number of studies which examine the relationship between 
blacks, alcohol consumption, and automobile accidents, but the existing studies conclude 
that blacks are at greater risk for accidents due to drinking than whites. This research 
suggests that during accident situations, blacks either exhibit higher blood alcohol 
concentrations (BAG) levels than whites, or are more vulnerable to accidents and arrest 
at the same BAG level as whites. 

A study by Waller et al., (1969) of persons involved in traffic fatalities found 
that inore blacks had been drinking than other groups and that a greater proportion had 
a BAG of .15% or higher. Of the blacks, 69% had been drinking while only ^5% of 
whites were drinking; 50.6% of the blacks had BAG'S above .15% whereas only 26.5% 
of whites had BAG'S at this level. 

In a study of 152 respondents and SOl'f drivers in Grand Rapids Michigan (Gosper 
and Mozersky, 1968), blacks stood out as having the highest percentage (2^*%) of BAG'S 
of .01% and over .0^%. This was in spite of the fact that blacks were more likely 
to abstain and less likely to drive than whites. Blacks also exhibited disproportionately 
high rates of drivers who were considered to be drinkers. 

Research on arrests for driving while intoxicated (ADWI) in Golumbus, Ohio, and 
Santa Glara County (Hyman, 1968b) found an overrepresentation of Blacks in Ohio and 
those with Spanish surname in California. Blacks were at least twice as likely to be 
arrested as other men, especially in age groups between twenty and sixty-four. Since 
the proportion of ADWI involved in accidents with above average BAC's was not lower 
among blacks, Hispanics, and unemployed than among others, the authors argued that 
police bias was not a significant factor in the overrepresentation of these groups for 
drunk driving arrests. In both areas, men living in low SES census tracts were vulnerable 
to arrest despite the fact that such households generally have less access to cars. 

In a related study of 9953 drivers who had been involved in accidents in Michigan, 
Hyman (1968a) found that there was little difference in the distribution of BAC's 
between blacks and whites. Yet blacks were more vulnerable to arrest in every category 
of BAG. Blacks tended to have higher accident vulnerability (AV) at each educational 
level in comparison to whites. For whites, educational attainment was inversely 
proportionate to AV level; for blacks those completing college and high school were 
more vulnerable than those with less education. 

Explanations for blacks' greater risk for high BAG levels and higher accident 
and arrest rates have focussed on factors such as social alienation, status deprivation, 
and psychic stress (Gosper and Mozersky, 1968; Hyman 1968a, b). However, since the 
mid-1960's when these studies took place, white rates of arrest for driving while 
intoxicated have risen greatly, equalling rates for blacks (see the section below). The 
new patterns coincide with the increased focus on drinking and driving in American 
society, signalled by the rise of grass roots movements such as Mothers Against Drunk 
Driving and tougher drunk driving laws. The decline in black predominance in drunk 
driving seems to be largely related to new enforcement patterns which crack down on 
white drivers as well as blacks, rather than to changes in blacks' intra-psychic make-up 
or changes in status and power relations between blacks and whites. 



98 



BLACKS, ALCOHOL AND CRIME 

Arrests for Alcohol-Related Offenses; 

The most striking finding regarding black arrests for alcohol-related offenses has 
been their enormous decline relative to white rates over the past two decades. In 
1965 the rate of black arrests for drunkenness in adults 18 years and above was over 
l^z times the rate for whites (27'tl.9 versus 9^+9.3 per 100,000 population). Blacks 
accounted for nearly one-fourth of all arrests for drunkenness although they constituted 
only a tenth of the U.S. population. In the intervening years, the rate of arrests for 
drunkenness has greatly declined in both groups, but the change has been more pronounced 
among blacks. By 1980, black arrests were occurring at only a slightly greater percentage 
than white arrests. Blacks accounted for about 16% of arrests for drunkenness, which 
is only about 5% in excess of their representation in the population. Much of this 
difference can be attributed to the greater urbanization and lower socio-economic status 
of blacks, since these factors were shown to influence rates of drunkenness arrests in 
some states (Skolnick, 195^). The large decline among both blacks and whites in the 
overall arrest rate is probably due to decriminalization of intoxication, changes in 
enforcement practices, and the expansion of treatment services. 

Racial differences in arrests for driving under the influence (DUI) exhibit a 
similar convergence. In 1965, black arrests for DUI were substantially higher than 
whites (303.5 versus 168.6 per 100,000 population), although blacks were less likely to 
drink and probably less likely to drive. Over time, arrests have increased in both 
groups, but the increase has been greater for whites (almost a four-fold versus about 
a two-and a half fold difference). Currently, blacks are about equally represented in 
DUI arrests in relation to their proportion of the population, and population rates 
between the two groups are very similar, 813.^ versus 808.2 per 100,000 persons. 



99 



Fig. 7 U.S. Arrest Rates for Drunkenness 

Persons 18 Years and Over by Race 
1965- 1982 



3 
Q. 
O 

a. 

o 
o 
o_ 

o" 
o 

q: 

UJ 
Q. 

hi 

\- 
< 
q: 



1600 
1200 
800 
400 



I I I 



i i I I 



I I I I I I I 



▲ Black 
O White 




>"0-0. 



"^x^'^-o-^-o-o-. 



o-o-o 



J_L 



I I ' I I I 



J. 



I ' I I I 



1965 



1970 1975 

YEAR OF ARREST 



1980 



Source: Uniform Crime Reports, Current Population Reports 



100 



Fig. 8 u. S Arrest Roles for Driving Under the Influence 
Persons 18 Yeors ond Over by Roce 
1965- 1982 



1000 



100 



I I I I I 




A Block 
O White 



I I I I I I I I 



J L 



I I I I 



1965 



1970 1975 

YEAR OF ARREST 



1980 



Fig. 9 



o 

I- 
< 



300 



o 
o 


180 


UJ 


140 


UJ 


100 


< 


60 



20 - 



U.S. Arrest Rates for Liquor Low Violotion 
Persons 18 Yeors ond Over by Race 
1965- 1982 



I I I I I I 



I I I r 



A Blocks 
O Whites 




;:.o-^°-^-o-o-o, 



'x^.d 



' I I I I I I 



I I I I I I I I I 



1965 1970 1 975 

YEAR OF ARREST 



1980 



Source: Uniform Crime Reports, Current Population Reports 



101 



«l. 



Arrests for violation of liquor laws (the category includes alcohol beverage license 
violations, unlawful possession, and illegal manufacture and sale) show a similar reversal 
of racial predominance. In 1965, the rate of arrests among blacks was nearly three 
times that of whites (231.0 versus 80.3 per 100,000 population). Blacks accounted for 
about one-third of all arrests although they comprised about a tenth of the population. 
Since the 1960's black rates have declined slightly and white rates have steadily 
increased. By the late 1970's, white rates surpassed those of blacks, and remained 
elevated until 1982. In 1982, black rates were slightly above rates for whites, 18^^.6 
versus 166.2 per 100,000 persons. 

Alcohol Involvement in Serious Crimes^ 

Data from arrest records, prison records, and interviews do not generally support 
the view that blacks are more likely than whites to have been involved in a crime 
with alcohol. When blacks with serious social and personal problems — such as those 
found among black prison offenders ~ are compared to similar whites, they are less 
likely to have drinking problems or to be heavy drinkers than whites (Roizen, 1981). 

Prison studies show that a smaller proportion of black than white male offenders 
were drinking at the time of the crime. Grigsby (1963) found that 26% of Black male 
offenders in Florida were intoxicated at the time of the crime, compared with 32% of 
whites. Mayfield's (1972) analysis showed that 53% of blacks in North Carolina were 
intoxicated, compared with 60% of whites. The 197^* LEAA survey (U.S. Department 
of Justice, LEAA, 1975) found 37% of blacks drinking at the time of the crime, 
compared with 50% of whites. The single study of women (Cole, Fisher and Cole, 1968), 
a study of women homicide offenders only, reports a larger proportion of black women 
drinkers (56%) compared to white women {ii5%). 

The differences between black and white samples in proportion drinking diminish 
dramatically with age for both broad categories of crime. Black property offenders 
over ^0 are only slightly less likely than Whites to have been drinking. Among those 
having committed crimes against the person, older black offenders are about as likely 
as whites to have been drinking. However, among young offenders — who are 
overrepresented in prison populations — blacks were less likely than whites to have 
been drinking at time of the crime. Again, blacks were less likely than whites to have 
been drinking heavily. 

Another measure of the relationship of drinking and crime is the prevalence of 
reported drinking problems in prison populations. Grigsby (1963) found in Florida that 
^^3% of white offenders were "regular drinkers" compared with 30% of non-whites; 
Globetti et al., (197'f) found in Mississippi that 56% of whites compared with 34% of 
blacks were "regular drinkers". Guze et al., (1962) found that 47% of white offenders 
in Missouri were labeled alcoholics, compared with 27% of blacks. The 1960 State of 
California survey of drinking problems of newly committed offenders, the largest of 
these studies, reports twice as many white as black offenders with drinking problems. 

Finally, homicide studies of jailed offenders show a more equal pattern of 
black/white alcohol involvement. Black offenders were as likely or more likely than _ 
white offenders to have been drinking at the time of the homicide (Roizen, 1981). ^ 



3. This section draws heavily from a review on blacks, alcohol, and crime by Roizen 
(1981) 



1 

i 



102 



SURVEYS OF DRINKING PATTERNS AND PROBLEMS IN THE ADULT POPULATION 

Nationed Surveys 

Since the 1950's, regular nationwide surveys of drinking patterns and problems 
have been conducted in the U.S. These surveys have included small subsamples of 
blacks which yield general information on black drinking patterns. Due to the small 
number and skewed geographical distribution of black respondents, they cannot be 
assumed to be reliably representative of the black population as a whole. In addition, 
because of differences in drinking measures, comparisons across different studies should 
be viewed with caution. Rates of drinking should be regarded as rough indicators for 
comparing differences between blacks and whites in the same study, and not as absolute 
measures of drinking patterns. 

The 196^^-65 national survey of drinking practices (Cahalan et al., 1969) included 
200 black respondents. The study showed that black and white men varied little in 
their drinking patterns. Roughly, 30% of the men in both races abstained or drank 
infrequently, nearly 50% were in the light-to-moderate category, and about 20% of the 
men were heavy drinkers. However black women differed from white women both in 
their much higher proportion of abstainers (51% versus 39%) and in their higher rate 
of heavy drinkers (11% versus 7%). 

In a study of problem drinkers based on a 1967 re-interview with a sub-sample 
from the 196't national survey (Cahalan, 1970), blacks, along with those of Caribbean 
and Latin, ancestry showed among the highest rate of social-consequence drinking 
problems. Blacks also exhibited very high scores for measures of alienation, and 
maladjustment, and for unfavorable expectations regarding personal achievement and 
happiness goals. 

Similar findings on the relatively high prevalence of black alcohol-related problems 
were described in a later study of problem drinking among American men (Cahalan and 
Room, 197^). The study combined two national samples (the data from 1967 with a 
new sample from 1969) with a total of 1561 adult males ages 21-59. The number of 
blacks in the sample was approximately 100. Blacks, along with those of Latin- American 
and Caribbean ancestry, showed the highest rates of heavy drinking. Blacks also 
exhibited among the highest rates of problem consequences from drinking. By controlling 
for socio-economic and other socio-demographic factors, black/white differences in the 
rates of black problems were considerably reduced. This finding suggests that high 
problems rates among blacks may be more a reflection of high risk social characteristics 
(e.g., poverty, residence in a large city, youthfulness) than of strictly racial or cultural 
factors. 

In more recent national surveys, blacks have reported higher rates of abstention 
and similar rates of heavy drinking compared to whites. In a study of attitudes towards 
alcohol education campaigns (Rappaport et al., 1975) blacks were more likely than 
whites to classify themselves as abstainers i'i-7% compared with 33%); both were equally 
likely to classify themselves as semi-abstainers (10%). Among those who reported 
drinking, about half (^9%) of the blacks were classisfied as infrequent drinkers, compared 
with ^0% of the whites. At the other extreme, 23% of blacks were classified as heavy 
drinkers, compared with 28% of whites. 

Clark and Midanik's report (1982) on the 1979 national survey of drinking practices 
also showed higher rates of abstention among black males and females (30% and 'f9% 
respectively) when compared to white men and women (25% and 39% respectively). 



103 



The study showed that white men had considerably higher rates of very heavy drinking 
than blacks (21% versus l't%); while black women had higher rates of heavy consumption 
than white women (7% versus ^%). White men were twice as likely as black men to 
exhibit social problems as a result of drinking (6% versus 3%), although black and white 
women were quite similar on this measure (2% and 3% respectively). 

Regional Surveys 

Urban North 

Studies examining black drinking patterns and problems in northern cities during 
the 1960's tended to show relatively high rates of heavy drinking and alcohol-related 
problems. However, most studies focussed on populations concentrated in high density, 
low socio-economic areas, which may limit their applicability to blacks in other settings. 

A study of drinking patterns among adults in Western New York State (Barnes 
and Russell, 1977), showed that rates of heavy drinking were considerably higher than 
national rates for the sample as a whole, as well as for black respondents The study 
was based on personal interviews with 1039 respondents randomly selected to represent 
households in Erie and Niagara counties. Blacks were proportionately represented in 
the study, but the number of black respondents was quite small (N=59). The major 
differences between black respondents and others wcis the high proportion of blacks 
(35%) who were abstainers, when compared to whites (13%). However, rates of heavy 
drinking were very similar, 2^^% and 23% respectively for blacks and whites. The rates 
of heavy drinking recorded in this region for both groups were about twice the rates 
recorded in the 196^-65 National Survey (Cahalan et al., 1969). The difference was 
attributed not only to increases in the rate of heavy drinking over time, but to regional 
differences in drinking patterns. The Northeast is traditionally "wetter" than other 
areas; hence, in the 196't-65 survey this area exhibited higher rates of heavy drinking 
than for the country as a whole (19% versus 12%). 

The comparatively "wet" patterns for New York State were replicated in a study 
of drinking patterns in the Boston area (Wechsler et al., 1978). A household survey of 
10^3 adults, including 112 black respondents, showed that generally there was a higher 
percentage of heavy drinkers than was found in Cahalan' s national sample. Only about 
17% of the total sample was classified as abstainers while 23% were described as heavy 
drinkers. Black and white males differed little in drinking patterns; about 13% of each 
group were abstainers, nearly half ranged between infrequent and moderate drinking, 
and 39% were categorized as heavy drinkers. However, black women had nearly double 
the rate of abstainers as white women (36% versus 17%, p .01). In contrast, the two 
groups of women exhibited very similar rates of heavy drinking, 11% and 12% 
respectively. 

In one of the first epidemiological studies of "alcoholism" in a community setting 
(Washington Heights in New York City), Bailey et al. (1965) showed that blacks, 
particularly black women, are subject to higher rates of "alcoholism" (defined as excessive 
drinking and/or presence of difficulties and problems due to drinking) than whites. 
Rates per 1,000 population were 37 for black men as compared to 31 for white men. 
Black women, however, exhibited a rate four times that of white females (20 versus 5 
per 1,000 persons). When the sex ratio o: alcoholism was calculated by race, the ratio 
for whites was 6.2 men to 1 woman, while that for blacks was 1.9 to 1. The high rates 
of "alcoholism" among black women were attributed to a permissive culture for female 
drinking, and to the greater tendency of black women to head households and be the 
major breadwinners. 



104 



Higher rates for blacks as a whole were reported in a related study on problem 
drinking in New York City residents (Habernnan and Sheinberg, 1967). Blacks had a rate 
of "implicative" or problem drinking which was twice the rate for white Protestants 
— 105 versus 'f9 per 1,000 persons. The low sex ratio of problem drinking among 
blacks observed in the previous study was also reported. The sex ratio for whites was 
^.0 men to 1 women, whereas for blacks it was 1.2 males to 1 woman. 

A more recent survey (Weissman et al., 1980) of alcoholism prevalence in the 
New Haven, Connecticut area echoed the findings of previous studies. Alcohol problems 
and psychiatric symptoms were assessed in a longitudinal study of a mental health 
catchment area in New Haven. The final wave of data were collected from ^■57 whites 
and 53 non-whites that had also been interviewed during 1967 and 1969. Respondents 
were asked a series of questions from the schedule for Affective Disorders and 
Schizophrenia (SADS) and the Research Diagnostic Criteria for Alcoholism (RDC). On 
the basis of these measures, the point-prevalence and lifetime-prevalence of probable 
and definite alcoholism was considerably higher among non-whites than whites. The 
point prevalence of Probable + Definite alcoholism was 9.5 per 100 persons for non- 
whites and 1.8 per 100 persons for whites. The lifetime prevalence of alcoholism for 
non- whites was 18.9 per 100 persons and only 5.2 per 100 persons for whites. In 
general, alcoholism rates were highest among males, the lower social classes, middle- 
aged and older groups and divorced, single or separated persons. 

Studies conducted in the St. Louis, Missouri area drew similar conclusions about 
high alcohol problems rates among blacks. Research on samples of men selected from 
elementary school records in St. Louis, revealed that heavy drinking was twice as 
common among blacks as among whites; and that problems from drinking were more 
than three times as common (Robins et al., 1968). Black men reported a broad range 
of legal, social, medical, and family problems due to drinking. About a third had a 
history of medical problems and family complaints; half reported personal concern about 
drinking excessively, and a fifth had either been arrested for alcohol-related offenses 
or had a public record of some drinking problem. 

Unlike other studies, Robins et al. (1968) de-emphasized the relationship between 
social status and prevalence of drinking problems among black males. Instead, high 
problem rates were attributed to the greater frequency of unstable homes and juvenile 
delinquency among blacks. The authors failed to recognize that socio-economic factors 
invariably affect family lifestyle, school performance and other "predictors" of adult 
drinking problems. 

A survey of housing project residents in St. Louis (Sterne and Pittman, 1972) 
reported very high rates of heavy drinking for a small sample of black men (50%) and 
very high rates of abstaining in black women (^^7%). No comparison group of white 
project residents was surveyed. However, when the findings were compared with survey 
results from groups of California blacks (see Berkeley 1960 and San Francisco 1962 
samples below), St. Louis project males had considerably higher rates of heavy drinking, 
but women in both places exhibited high rates of abstention. Drinking patterns were 
found to be related to sex, church attendance, attitudes toward drinking, and to a 
lesser extent, age, socioeconomic status and some aspects of sociability. Little direct 
information on alcohol-related problems was collected in this study. However, "street 
drinking" health, and marital problems were discussed by project residents in another 
survey and in ethnographic interviewing. 

In contrast to the high rates of heavy drinking and alcohol problems described 
for most black adults in the urban north, a study of drinking patterns of the black 



105 



elderly (3ohnson, 197'f) suggested this group may be at less risk for problems than 
younger blacks. In a study of the drinking patterns and health status of persons over 65 
in the upper east side of Manhattan, considerably more blacks were described as being 
abstainers than whites, 51% and 37% respectively. Similarly blacks were about half 
as likely to report being frequent drinkers as whites (17% versus 32%). Among blacks 
and whites, those in good health were more likely to be drinkers than those in poor health. 

Southern States 

Very few studies have explored the drinking patterns of black adults in the South. 
Only three surveys were described in the contemporary literature, and two of these 
took place in Mississippi prior to 1965 when much of the state was under prohibition. 

All three of the surveys report high rates of abstention among black respondents; 
rates which are somewhat higher than whites in the South and considerably higher than 
whites and blacks in other regions. 

Globetti's survey of 108 black respondents in Mississippi reported that only 36% 
of the sample had used alcohol twice in the year prior to the study. (A comparable 
study showed about 't^% of whites in Mississippi to be drinkers). Among blacks, 60% 
of the males and 76% of females were classified as abstainers. Of the drinkers, most 
drank infrequently (1-15 times per year) and in small quantities (1-2 drinks per sitting.) 

Reasons for high rates of abstaining and low rates of drinking among blacks were 
attributed to the same socio-environmental factors that affect rates among whites. 
These include legal prescriptions against alcohol use and restrictive religious norms, 
and socio-demographic factors such as low levels of educational attainment and low 
socio-economic status. 

High rates of abstention were also reported in a study of contrasting Mississippi 
communities (Windham and Aldridge, 1965). Blacks (N=183) and whites (N=395) were 
surveyed in a study of alcohol attitudes in two Mississippi communities ~ one located in 
a Delta community where use of beer is permitted, the other in a completely "dry" 
hill community. In general, black rates of abstention {?'*%) were higher than white 
rates (67%). As expected, rates of drinking were higher for both blacks and whites in 
the more permissive Delta area than in the hill community. However, black rates of 
drinking were lower than respective rates for whites in each community. 

Low rates of black alcohol consumption were again reported in a more recent 
epidemiologic study of drug use in a Florida county (Warheit et al., 1976). Although 
there are few racial differences in overall rates of drug use, there were significant 
differences in the use of alcohol by race. About 71% of the whites compared to 43% 
of the blacks reported using alcohol. Black males were more than twice as likely as 
black females to report drinking (61.3% versus 30%). There was less difference between 
white males and females (80% versus 60%). 

Whites also reported using alcohol more frequently (frequent use was defined as 
use everyday, all of the time or often) than blacks. The race-sex differences were 
quite dramatic; 31% of the white males said they drank alcoholic beverages frequently 
compared to only 3% of the black females. About 20% of both white females and 
black males reported frequent use of alcohol. 

The low rates of reported consumption by blacks was attributed to strong religious 
proscriptions regarding drinking, which would both inhibit actual drinking and also make 
drinkers less willing to report their use of alcohol. 



106 



The West 

Data on black drinking patterns in California have been collected through a series 
of larger general population surveys dating from the early 1960's through the mid- 
1970' s. The studies generally portray similarity in overall patterns of black and white 
drinking, except for higher rates of abstention among blacks, particularly women. 

One of the first studies to report on black drinking practices in California took 
place in Berkeley in 1960 (Knupfer and Lurie, 1961). About 100 blacks were interviewed 
in a study involving a probability sample of the adult population of the entire city. 
Considerably more blacks were abstainers than whites (32% versus 20% of those 
interviewed). Black and white males exhibited similar rates of heavy drinking (28% 
and 29%, respectively), but significantly more white females were heavy drinkers thcin 
black females (15% as compared to 7%). 

Similar results were obtained in a survey of drinking patterns in San Francisco 
in 1962. About 123 black respondents were included in the study. Again, a considerably 
greater proportion of blacks were abstainers when compared to whites (32% versus 21% 
of those interviewed) and significantly more white females were heavy drinkers thein 
black females (15% as compared to 7%). 

A later study (Cahalan and Treiman, 1976) of drinking patterns in a general 
population survey of San Francisco showed particularly low rates of heavy drinking, 
intoxication, and drinking problems among black respondents compared to white 
Protestants. Only 1% of blacks compared to 10% of white Protestants, were 
characterized as frequent heavy drinkers. Over half the black respondents (56%), but 
only a quarter (25%) of white Protestants, were described as infrequent drinkers or 
abstainers. Blacks were ranked considerably lower than white Protestants on alcohol 
problems indices such as high intake, symptomatic drinking, and loss of control. However 
Blacks reported similar rates of marital problems eis whites. 

A more recent study of an all-black sample in San Francisco (Lipscomb and 
Trocki, 1981) found higher rates of heavy drinking than the Cahalan and Treiman study 
(1976) using a similar quantity-frequency measure of drinking patterns. The later study 
found that 7% as opposed to 1% of blacks interviewed were frequent-heavy drinkers. 
However, identically high rates of abstention and infrequent drinking were recorded for 
blacks in both surveys. The discrepancy in rates of heavy drinking observed in the 
two surveys could be due to increases in heavy drinking among blacks. However, the 
stability of abstaining and moderate drinking suggests that the differences may be due 
to the difference in sample bases in the two studies. The later study included a much 
larger number of blacks living only in black neighborhoods, and would be expected to 
give a broader range of variation in drinking patterns. 

In contrast to the moderate rates of heavy drinking described for San Francisco 
blacks, a statewide study of California drinking patterns in 197'f with 83 black respondents 
(Cahalan, 1976, and Cahalan et al., 1976) showed comparatively high rates of heavy 
drinking among blacks. About 15% of blacks and only 9% of whites interviewed were 
heavy drinkers. Yet, as in earlier studies, blacks were considerably more likely to be 
abstainers than whites (29% versus 15%). Rates of problems were similar as a whole 
for blacks and whites (10% and 9%, respectively). 



107 



Black Drinking Patterns in Northern California 

Between 1977 and 1980, a large-scale survey of black drinking patterns took 
place in the San Francisco Bay Area. The study was conducted through three surveys 
on random samples of the general population in three California counties. PersonaJ 
interviews were conducted over a period of three years with a total of ^^,510 adults 
between the ages of 18 and 59 years to evaluate a state funded alcohol problems 
prevention campaign (Wallack and Barrows, 1981). Combined samples included 1,206 
persons who identified themselves as "Black, Afro-American or Negro." Data on 
substantial numbers of whites and Hispanics were also provided through the survey. 

The results of the study permitted a more detailed analyses of the effect of 
social-demographic variation on black drinking patterns than had previously appeared 
in the literature (Caetano, 198^^). At the aggregate level, the survey showed a picture 
of black drinking that was highly consistent with previous studies. Black and white 
males had almost identical rates of frequent heavy drinking, although black men were 
considerably less likely to be frequent high-maximum drinkers than white men. Black 
men were also more likely to be abstainers than white men. Hispanic men had lower 
rates of abstention and higher rates of frequent heavy drinking than men of the other 
two groups. 

Black and Hispanic women exhibited much higher rates of abstention than white 
women. Women's drinking in all three ethnicities was concentrated in the occasional 
or infrequent categories. White women were more likely to be frequent drinkers in 
either the low or high quantity category than either black or Hispanic women. However, 
black women were more likely than white or Hispanic women to be classified as frequent 
heavier drinkers. 

One of the major findings of the study which had not previously been reported 
in the literature, was that there are striking differences between the ethnicities in 
rates of heavy drinking for males according to age group. Among whites, frequent 
heavy drinking was concentrated among young males between 18-29 years old, but 
rapidly declined and stabilized after males reached the 30-39 year age group. Among 
black males, however, frequent heavy drinking was relatively uncommon in the younger 
age group, but rose dramatically for men between 30-39 years old. Rates of heavy 
drinking gradually declined mong middle-aged and elderly blacks. Hispanics showed a 
different pattern in which heavy drinking was very high in young men and in men aged 
30-39. However, rates of heavy drinking declined substantially in late middle-aged and 
older Hispanics. 

As previously noted, the prevalence of heavy drinking in older blacks may increase 
their vulnerability to physiological problems. The later onset of heavy drinking among 
blacks may be associated with more sustained patterns of high consumption than among 
whites, where heavy drinking is a short-term youthful phenomenon. This prolonged 
pattern of heavy drinking is associated with high risk for alcohol-related chronic diseases. 

Black and white men exhibited similar rates of current alcohol problems, which 
were lower than rates reported by Hispanics. The highest ranked problem for men, 
regardless of ethnicity, was spouse or family concern about drinking. Health problems 
due to drinking ranked second among blacks, whites, and Hispanics. Very low rates of 
alcohol problems were recorded for women of all three ethnicities. However, black 
and Hispanic women were more likely than white women to report spouse or family 
member upsets due to drinking. 



108 



For all three ethnicities, the number of drinks per month and frequency of 
drunkenness were the strongest predictors of the number of drinking problems. For 
males, the prevalence of four or more problems paralleled differences in the peak ages 
of heavy drinking. Problem prevalence for white males was highest for men between 
20-29 years, after which it declined sharply. Among blacks and Hispanics problems 
were low in young males and abruptly rose in the 30-39 group. Problem rates declined 
considerably for males over W and even more dramatically for those over 50. 

In a separate analysis of black respondents using the same data set, additional 
insight Wcis gained on specific factors influencing black drinking problems (Herd and 
Caetano, forthcoming). In general, the analysis revealed that socio-economic factors 
are less strongly associated with black drinking patterns than is true in the general 
population. The association of income, education and employment status with amount 
of drinking did not reach significance in a regression analysis on male drinking patterns. 
Only the variable of fundamentalist religious affiliation reached statistical significance 
~ and as might be expected, the association with drinking was negative. Among 
females, however, marital status (being married or living together) and being older, 
along with religious fundamentalism, were negatively associated with drinking. 
Employment was positively associated with drinking for women. 

In general, the study concluded that internalized norms ~ like religious beliefs 
and attitudes towards womens' roles and conduct ~ may have comparatively more 
influence on black drinking patterns than socio-economic factors. 



109 



SURVEYS OF DRINKING PATTERNS AND PROBLEMS 

AMONG YOUTH AND COLLEGE STUDENTS 

Studies of Adolescents 

Until recently, the literature on black drinking practices argued that blacks were 
"precocious" in adopting lifestyles of heavy and problem drinking. Alcohol was believed 
to be pervasive in ghetto environments, leading to the early and widespread initiation 
of black youth into adult drinking patterns (Sterne and Pittman, 1972). These patterns 
were seen as a precursor to blacks' involvement in alcoholism treatment and contact 
with alcohol problems agencies at younger ages than whites (Robins et al., 1968). 

However, surveys of youth in the general population have been consistent in 
showing that fewer black than white adolescents drink at all and that those who do 
drink, get drunk less often than whites, and have lower rates of heavy and problem 
drinking than whites. 

Blane and Hewitt's review (1977) of the literature on adolescent drinking from 
1960-1975 reported that most surveys of black youth showed that they were less likely 
to use alcohol or to experience problems related to drinking. Surveys of high school 
students usually indicated lower rates of lifetime and current alcohol use, lower drinking 
frequency, and lower rates of problem drinking. Similar findings were reported for 
black youth respondents in household general population surveys and in a study of 
selective service registrants. The results of studies on delinquent and problem youth 
were less consistent — with some showing higher rates of heavy and problem drinking 
among blacks than whites. But even in this population, the review concluded that 
overall use rates were lower among blacks than white high school students. 

Studies of adolescents published since this review continue to report lower rates 
of drinking among blacks. A national survey of drug use among the youth and adult 
population (Fisburne et al., 1979) found that black youths aged 12-17 were less likely to 
be current drinkers than whites (29% vs. 38%) and that the proportion of drinkers 
among blacks increased less over a 5 year period than among whites (10% vs. l't%). 
A nationwide survey of youth in secondary schools (grades 7-12) (Wilsnack and Wilsnack, 
1978) found that black girls and boys were more likely to abstain than whites, Spanish 
American, or Native American youth across all grade levels. In grades 11-12, only 'f'f.2% 
of black girls reported drinking in comparison to 67.7% of whites, 53.9% of Hispanics, 
and 61.2% of Native American girls. The same trend held for males. Only 63.3% of 
black males, compared to 80.^% of whites, 8'f.l% of Hispanics, and 72.3% of Native 
Americans were drinkers. Blacks also ranked low on mean quantity-frequency scores 
and scores of symptomatic drinking. Wilsnack and Wilsnack (1980) also reported that 
drinking was not as predictive for problems with achievement motivation or sense of 
responsibility among blacks, Jews, or Catholics, as among the majority population. 

A recent analysis of a nationwide survey of senior high school students examined 
the drinking patterns of a representative sample of 496 black students (Harford et al.. 
1982). The results of the study showed that more black boys (3't.3%) and girls (^^0.6%) 
abstained or used alcohol less than once a year than white boys (19%) or girls (23%). 
Blacks also reported higher rates of infrequent drinking than whites. Although the 
study found that black students' drinking levels were influenced by demographic factors 
(grade level, sex, geographical region) and academic performance, these factors failed 
to completely explain the difference between white and black drinking patterns. The 
study concluded that there are important stylistic differences between blacks and whites 



110 



in the use of alcohol and other drugs which relate to a delay in onset of drinking 
among black youth. 

Youth and Criminal Offenses Related to Alcohol 

Data on arrest rates for alcohol-related offenses for youth under 18 years of 
age offer strong support for the findings from general population surveys which show 
that black adolescents and high school students abstain more, drink less frequently, and 
drink lower quantities of alcohol. These data reveal that rates for blacks are currently 
far below those of whites, and that over time, rates for white youth have increased 
much more dramatically than rates for blacks. 

In 1965, black rates for driving under the influence among those under 18 were 
about half those of whites (1.2 versus 2.8 per 100,000 population). Over the years, 
particularly after 197^^, rates among both groups increased greatly, but increases for 
whites were much higher than for blacks. Between 1965 and 1979, the rate for blacks 
increased about ninefold (from 1.2 to lO.'t per 100,000 population), but in the white 
population, rates increased almost 20 times above their former level (2.8 to 5^.8 per 
100,000 population). Currently, rates for whites are about 6 times higher than in the 
black population, 46.8 and 7.2 per 100,000 population respectively. 

Changes in arrest rates for liquor law violations show a similar pattern. In the 
mid-1960's, rates among white youth were about Th times in excess of rates for blacks, 
or 70.9 versus 23.0 per 100,000 population. Between 1965 and 1982, rates among blacks 
almost doubled; but they nearly tripled in the white population. In 1982 rates for 
whites were nearly 6 times those in the black population (218.8 versus ^^1.3 per 100,000 
population). 

Arrest rates for drunkenness exhibit a different pattern, yet they also illustrate 
the strong predominance of white relative to black alcohol- related offenses. Since 
1965, black arrrest rates have fluctuated, showing modest increases in the late 1960's 
and early 1970's, but eventually declining to about half their initial level. In 1965, 
black arrest rates for drunkenness were 31.2 per 100,000 persons; yet by 1982 the rate 
had fallen to 17.9 per 100,000 population. In contrast, rates among whites have shown 
steady increases over time. By 1977, rates among whites had more than doubled, from 
35.0 to 85.5 per 100,000 population. Since that time, white rates have declined but 
they remain considerably higher than rates for blacks, 60.7 versus 17.9 per 100,000 
population. 



Ill 



Fig. 10 us. Arrest Rotes for Driving Under the Influence 

Persons Under 18 Years By Race 
1965—1982 




1965 



I97D 1975 

YEAR OF ARREST 



1960 



Fi g ■ 11 us. Arrest Rotes for Uquor Low Violation 

Persons Under 18 Years By Race 
1965- 1982 







1 1 1 1 1 1 1 1 1 i 1 1 1 1 T'~T 


o 

2 260 








A Block 


_ 


°^- P'O-c^ . 


2 220 


: 


/ ^'■: 


O 180 
O 


- 




o 




t ~ 


O 140 


— 




ie 100 

A. 


-,cx 


UJ 


r 




1- 60 




• 


< 






o: 


^ 




20 


_L 


1 1 1 1 1 1 1 1 1 1 1 _ 



1965 



I97D 1975 

YEAR OF ARREST 



1960 



Source: Uniform Crime Reports, Current Population Reports 

112 



Fi g . 1 2 U. S. Arrest Rotes for Drunkenness 

Persons Under 18 years By Race 
1965- 1982 



s 

E 



o 
o 
o 

O 

o 



oc 

Q. 

Vi 
UJ 

I- 
< 
DC 



100 
80 
60 
40 
20 



I I I I I I I I I I I I I I I 



A Block 
O White 






9^ A 
/ V ^a 

9-6 ^ 



I I t 



1965 



1970 1975 

YEAR OF ARREST 



\5 - 




I I ' ' ' ' I ' I ' I 



1960 



Source: Uniform Crime Reports, Current Population Reports 



113 



College Student Surveys 

Earlier studies of college drinking indicated either that black and white males 
exhibited similar drinking patterns (Straus and Bacon, 1953) or that blacks were more 
likely to be heavy drinkers than whites (Maddox, 1968). Reported rates of problems 
and social complications due to drinking were similar between the two groups, cilthough 
blacks were believed to be more "preoccupied" with alcohol and to experience more 
feelings of ambivalence and low self-esteem about drinking (Maddox and Borinski, 196't). 

More recent studies, however, report findings that are consistent with the low 
rates of drinking described for black high school age youth. Eng's study (1977) of 13 
colleges included 2 predominantly black colleges, leading to the inclusion of 19't blacks 
in the study. The findings revealed that considerably more whites (8'f%) than blacks 
(60%) drank and about three times as many whites as blacks appeared to be heavy 
drinkers. When the findings were broken down by sex, they showed moderate differences 
in overall rates of drinking and striking differences in rates of heavy drinking among 
males. More white men (86%) than blacks (72%) reported drinking at least once a year 
and over four times as many white men as blacks were classified as heavy drinkers, 
22% versus 5%. Considerably more black woman were non-drinkers than white women 
(^^8% versus 18%); yet approximately the same percentage of white (5%) and Black (4%) 
women were reported to be heavy drinkers. 

A survey of drug use (Strimbu, 1973) in a large southeastern university system 
echoed these findings. Overall, blacks were less likely to use alcohol and drugs than 
whites. Blacks in predominantly white schools were more likely to be drinkers than 
those in black schools. 

The apparent shift in black college drinking patterns may be a reflection of 
several factors. First the change may reflect cohort differences in rates of heavy 
drinking, where drinking was more popular for youth in earlier decades. Second the 
shift may stem from changes in the socio-economic status of black college students as 
this population has expanded from a small well-to-do group in the 1950's to a more 
diverse group which includes middle and working class blacks. 



114 



NORMS AND VALUES REGARDING ALCOHOL USE 

Afro-Americans like other Americans of Protestant and rural southern heritage, 
exhibit polarization in attitudes towards alcoholic beverage use. This polarization is 
evident in the disparate images which have emerged regarding black drinking. The 
first, drawing on popular stereotypes and anthropological studies of ghetto life (Hannerz, 
1970; Liebow, 1967; Lewis, 1955) characterizes drinking and drunkenness as prominent 
and thoroughly integrated features of black life. 

In contrast, other studies suggest that anti-alcohol attitudes are perveisive in the 
black population. Borker et al., (1980) found ambivalent, or even hostile attitudes 
towards alcohol use among lower and working San Francisco blacks from fundamentalist 
backgrounds. The study concluded that among blacks there may be many norms 
restricting the use of alcohol, and general acceptance of abstaining or drinking 
infrequently by community members. 

A previous ethnographic study of a St. Louis lower income housing project (Sterne 
and Pittman, 1972) drew similar conclusions. The authors suggested that although 
alcohol was "near-successfully" integrated into black culture, liquor was negatively 
regarded and subject to ambivalent norms even among informants who were regular 
drinkers. They concluded that "consensus regarding alcohol use and consistency between 
drinking practices and attitudes is incomplete" (p. 653). 

Support for both perspectives ~ e.g. that black culture supports attitudes for 
patterns of heavy drinking and for abstaining ~ is evident in the previous review of 
survey data and social indicators of drinking patterns and problems. The findings 
illustrate that a significant portion of the population abstains, but that heavy drinking 
and high rates of alcohol problems are prominent in some sub-groups. 

A recent analysis by Herd (forthcoming a) suggested that the "two worlds" of 
drinking in black life stem from historical changes in the shift from the temperance- 
oriented values of the 19th century to the emphasis on liquor and the nightclub culture 
in the prohibition era. The Protestant church, especially its fundamentalist branches, 
has retained its sanctions against alcohol use and continues to be a force for abstinence 
in the black community. The orientation towards abstinence extends to church-based 
self-help groups and even to secular organizations for self-improvement (Borker et al., 
1980). 

The importance of religious values in shaping black perceptions of alcohol use 
are illustrated by the data from a recent anthropological study of black drinking patterns 
among urban blacks (Herd, 1980). Respondents from fundamentalist backgrounds reported 
a pattern of non-drinking by parents and female relatives. These informants reported 
that alcoholic beverages were seldom kept at home or served with meals, and were 
used only during holidays or special events. The respondents' current attitudes towards 
alcoholic beverage use was often quite ambivalent. Even among drinkers, alcohol was 
described as a potent and dangerous substance. 

In addition to negative attitudes towards alcohol itself, negative attitudes towards 
drunkenness have been described as characteristic of blacks in anthropological studies 
(Borker et al., 1981; Sterne and Pittman, 1972). These studies report that there is 
great emphasis on maintaining control of oneself in drinking situations and minimizing 
social disruption due to drinking. 



115 



Although anti-alcohol sentiments are sanctioned and reinforced in many black 
social contexts, the focus on drinking establishments and alcohol use associated with 
the nightclub culture during and after prohibition has also left a lasting impression on 
black social life. Bars, taverns and nightclubs have retained an important place in 
black society because they provide a context for sociability, dancing and listening to 
music. Alcohol is intrinsically associated with these establishments, as it is with 
informal contexts — such as house parties — which have the same focus. In these 
settings, drinking alcohol is regarded as an important symbol of sociability and pleasure 
(Borker et al., 1980). 

As a holdover from prohibition, liquor also plays a key role in the economy of 
black communities. Off-sale liquor establishments are regarded as one of the most 
viable forms of individual entrepreneurship available to blacks (Mosher and Mottl, 1981). 
The liquor industry views blacks as a primary market for distilled liquors, and thus is 
very visible through advertisements and promotional campaigns in local and nationcil 
black publications. 



116 



SUMMARY 

This review has examined a range of social indicators of alcohol problems among 
the U.S. black population. These include physiological consequences such as alcohol- 
related morbidity and mortality as well as pyscho-social indicators such as records on 
hospitalization or treatment for alcohol problems, arrest statistics, and self-reported 
social problems due to drinking. 

The findings of the review illustrate that, except for the youth population, blacks 
are overrepresented on most indirect measures of alcohol problems. However, there 
is considerable variation in the level of disparity between blacks and whites on different 
types of problem indicators, and variation in whether indicators of specific problems 
have been declining or rising in recent years. 

Medical problems associated with heavy drinking have increased very dramatically 
in the black population. Rates of acute and chronic alcohol-related diseases among 
blacks, which were formerly lower than or similar to whites, have in the post-war years 
increased to almost epidemic proportions. Currently, blacks are at extremely high risk 
for morbidity and mortality for acute and chronic alcohol-related diseases such as 
alcoholic fatty liver, hepatitis, liver cirrhosis, and esophageal cancer. 

The literature has pointed out that heavy alcohol consumption, both in the past 
and the present are strong predictors of increases in alcohol-related diseases (Schmidt 
and DeLint, 1972; Skog, 1980; Bruun, et al., 1975). With reference to past alcohol 
consumption patterns. Herd's research (forthcoming b) has described the shift in black 
cultural attitudes towards alcohol which has lead to alcoholization in many urban black 
communities since the Repeal era. The significance of these historical shifts was 
affirmed in an epidemiological analysis which showed the importance of cohort changes 
in mortality patterns and demographic shifts ~ such as urban migration ~ in partially 
explaining the rise of liver cirrhosis among blacks. An analysis of contemporary black 
drinking patterns suggested that blacks may be at greater risk for physiological diseases 
due to a later onset and more prolonged pattern of heavy drinking than whites. 

Aside from alcohol consumption level, other factors which may be important in 
explaining the high black rates of alcohol-related diseases have not been specifically 
explored. These include the possibility that high hepatitis rates, inferior nutritional 
status, and low socio-economic status may be leading to substantial increases in morbidity 
and mortality among blacks who drink heavily. 

In contrast to the rise of medical problems related to alcohol use among blacks, 
reflected in a widening disparity of problem rates between blacks and whites, some 
social indicators have shown have shown a relative decline in black predominance and 
a convergence of black with white rates. This has been the case with statistics on 
arrests for alcohol-related offenses. 

Arrests for drunkenness have decreased more substantially for blacks than whites, 
making the two groups more similar in rates than they were in the 1960's. Although 
black rates are still significantly higher than white rates, the disparity between the 
two groups has lessened greatly. Arrest rates for violation of liquor laws have also 
declined for blacks, but have increased in the white population, making rates between 
the two groups very comparable. Among both blacks and whites, arrest rates for 
driving while intoxicated have increased substantially, but the increase in white rates 
has been twice that of blacks. DUI arrest rates for blacks are now almost identical 
to rates for whites. 



117 



The decline of black predominance in arrest statistics seems to be related to 
general changes in the social and legal response to alcohol problems. These include 
the decriminalization of public drunkenness and expansion of alcohol detoxification and 
treatment centers. Legal responses refer in part to the increases in drinking and 
driving legislation and rise of grass roots anti-drunk driving movements. The changing 
legal response to alcohol problems have made white drinking drivers more vulnerable 
to arrest, thus helping to equalize black and white arrest rates. 

Black Americans are currently overrepresented in the alcohol treatment system, 
particularly in the urban areas of the Northeast. The excess involvement of blacks in 
the alcohol treatment system is consistent with the high rates of psychiatric 
hospitalization for alcohol problems described for urban, migrant blacks in earlier 
decades. Within the current alcohol treatment system, blacks appear to be modestly 
overrepresented in programs emphasizing voluntary treatment for working or middle- 
class people such as employee assistance programs. In contrast they appear greatly 
overrepresented in programs designed for persons in the lower socio-economic strata, 
such as public inebriates. 

The high proportion of blacks in the alcohol treatment system, particularly in 
agencies serving the poor and homeless, may be related in part to the general over- 
institutionalization of blacks in the mental health and criminal justice system. Blacks 
may be channeled into alcohol treatment agencies in a disproportionate manner due to 
their vulnerability to the legal system and to their lack of adequate socio-economic 
resources. Hence, alcohol treatment agencies may used to provide public welfare and 
employment rehabilitation services for economically marginal blacks, as much as to 
provide specific treatment for alcoholism. 

When rates of excessive drinking and rates of self-reported drinking problems 
are examined for the black population, no consistent patterns of high alcohol consumption 
or high problems rates emerge for the group as a whole. Black drinking patterns appear 
heterogeneous and differ along lines similar to patterns reported in the general American 
population. Rates of drinking vary greatly by geographical region, sex, and religiosity. 
Rates of alcohol problems show similar variation, with rates particularly high in urban, 
ghetto areas. 

There are however, important differences reported in black/ white drinking 
patterns. Blacks differ from whites in consistently reporting higher rates of abstention, 
particularly among women, across all geographical regions. At the same time, the 
black population exhibits a lower male/female ratio for heavy drinking and alcoholism 
than the white population. Hence, black women appear at greater risk for alcohol 
dependency and associated problems than their white counterparts. 

Another major difference in black versus white drinking patterns appears to be 
the ages of onset and termination of heavy drinking (Caetano, 1984). Among white 
males, heavy and problematic drinking is concentrated in the young, while among blacks 
this pattern is associated with early middle age. Accordingly, black youth report lower 
rates of drinking and drunkenness than whites and have extremely low rates of alcohol 
problems indicators such as arrests for alcohol-related offenses. Black males begin to 
report high rates of heavy drinking and social problems due to drinking after the age 
of 30. This pattern of later onset, if it leads to prolonged, heavy consumption, may 
put black males at greater risk for chronic diseases related to alcohol consumption such 
as liver cirrhosis and esophageal cancer. 

Ironically, despite the fact that blacks appear to adopt heavy drinking lifestyles 
at older ages than whites, the treatment population of blacks with alcoholism and 



118 



similar disorders seems considerably younger than the white population. This dilemma 
has not been adequately addressed in the literature, but may stem from differences in 
the social and economic background of the treatment population when compared to the 
population of respondents in general population surveys. 



119 



RECOMMENDATIONS FOR INTERVENTION AND RESEARCH 

Strategies for Intervention into Black Alcohol-Related Problems 

The previous review and summary suggests that medical problems associated with 
heavy alcohol consumption present the area of greatest disparity in black/white alcohol 
problems indicators. Reducing morbidity and mortality from liver disease and cancer 
and other alcohol-related diseases should thus be a major focus of alcohol problems 
intervention and prevention in the black population. The following section will discuss 
direct and indirect approaches for decreasing problem prevalence in both clinical and 
non-clinical populations. 

Prolonged heavy alcohol consumption is regarded as a key etiological agent in 
chronic liver disease (non-biliary cirrhosis), fatty liver, alcoholic hepatitis, and cancers 
of the esophagous and pancreas (Bruun et al., 1975; Turner et al., 1977). Epidemiological 
and clinical research has shown that heavy drinkers (persons consuming over 160 grams 
of alcohol per day) are at substantial risk for developing alcohol-related diseases 
(Lelbach, 1975, 1976; Pequignot, 1978). Reducing or eliminating alcohol consumption 
is thus regarded as the primary direct means of reducing incidence of these diseases 
or improving their prognosis once they have been diagnosed (Rankin et al., 1975; Hermos, 
198^^). 

In clinical populations, reducing alcohol consumption has been attempted both 
through alcoholism treatment and through routine medical advice. Although both 
approaches are valuable, medical advice to cut down on drinking may be a more efficient 
means of reaching large numbers of the population. Medical advice has been shown to 
be effective in reducing alcohol-intake for persons diagnosed with liver disease (Hermos, 
1984) and for persons with marital and social problems related to alcoholism (Edwards 
et al., 1977). Implementation of medical advice for reducing drinking would involve 
more emphasis on assessing patient drinking patterns and more systematic patient 
education about the effects of alcohol on the body than is currently accepted in medical 
practice. 

Reducing and preventing alcohol problems in the general population is associated 
with lowering rates of per capita alcohol consumption through price controls, taxation, 
restriction in number of alcohol outlets and hours of sale, and raising the legal age of 
alcohol consumption (Beauchamp, 1980; Cook, 1983; Rankin et al., 1975). Several black 
communities in California have initiated efforts to reduce numbers of alcohol outlets 
to help alleviate crime and social problems in their communities (Wittman, 1980). These 
efforts could be enhanced by strengthing the power of local communities to regulate 
the number, type, and hours of sale of alcohol outlets within their bounds. However, 
placing controls on alcohol beverage outlets need to be augmented with other strategies 
since the relationship between alcohol outlets and disease prevalence is complex. The 
association of alcohol beverage outlets with cirrhosis rates has been shown to be greatly 
influenced by other factors such as urbanization and low socio-economic status (Tokuhata 
et al., 1971). 

Other means of controlling alcohol availability such as taxation and age controls 
on drinking could not be implemented at the local level since they are under state or 
federal jurisdiction. In addition, these measures may not respond to the specific 
problems of alcohol availability experienced by blacks. For example, raising the age 
of alcohol beverage consumption is a measure to reduce alcohol-related problems among 
youth. Hence, this strategy would be inappropriate for significantly reducing black 



120 



alcohol problems since black youth are already at very low risk for problems, while 
those over 30 experience very high problem rates. 

Economic factors may be a particularly important area to take into consideration 
when planning intervention strategies which address the special needs of the black 
population. Alcohol use appears to be more directly tied to economic factors among 
blacks than among other sectors of the population due to the limited economic base 
of most black communities. For example, alcohol outlets appear to be one the more 
viable forms of entrepreneurship available to blacks. These outlets were regarded as 
a good economic risk by the Small Business Administration ~ in 1978 38% of alcoholic 
beverage loans and 50.9% percent of liquor store loans went to minority applicants 
compared with 18.9% of nonalcoholic beverage loans (Mosher and MottI, 1981). Concerns 
about employment opportunities for blacks have made some politicians vocal in urging 
that more blacks be hired by the alcoholic beverage industry (e.g. the boycott against 
Budweiser beer led by Jesse Jackson to force the company to hire more blacks at the 
management level). 

The problem of increasing blacks occupational association with alcoholic beverages 
is illustrated by Terris' (1967) epidemiological analysis which showed that persons in 
occupations where alcoholic beverages are regularly used or served (bartenders, waiters, 
retailers, workers in entertainment and recreational businesses) experience much higher 
rates of cirrhosis mortality than persons in other occupational groups. Reducing the 
occupational association of blacks with alcoholic beverages may thus be an important 
measure for intervening in alcohol-related diseases among blacks. This strategy requires 
an expansion of economic and social opportunities for blacks which could be facilitated 
in part by economic incentives that favor non-alcohol related businesses. 

Blacks also appear to be a prime target for advertising by the alcohol beverage 
industry. Alcoholic beverage advertising specially tailored for black audiences is 
pervasive in all forms of black-oriented media. Although the relationship between 
cilcohol beverage advertising, alcohol consumption, and rates of alcohol problems is 
complex, some research suggests that blacks account for a disproportionate share of 
the market for expensive brands of hard liquor (Bauer, 196^*). 

To counteract the effects of heavy alcoholic beverage advertising, alcohol 
education awareness needs to be fostered among the professional and lay black population. 
Political leaders, health professionals and the public at large have little knowledge of 
the extent to which blacks are affected by alcohol-related diseases. Nor is there 
adequate knowledge about the medical consequences of alcohol use. Public campaigns 
to facilitate awareness and knowledge about alcohol-related diseases may help prevent 
or facilitate early-case finding for these diseases among blacks. 

Along with focussing on reducing alcohol consumption, raising the general health 
status of the black population may help reduce morbidity and mortality from alcohol- 
related diseases. The disparity in black/white mortality levels may be generated in 
part by high case fatality rates due to undernutrition, poor health status, and lack of 
access to medical care. 

Differences in rates of hepatitis among blacks and whites may also influence 
the disparity in black rates for certain alcohol-related diseases. The presence of 
hepatitis B infection and antibodies or antigens seems to be associated with elevated 
risk for liver cirrhosis and liver cancer among heavy drinkers (Mills et al., 1972; Hislop 
et al., 1980; Brechot et al., 1982). Hepatitis appears endemic in lower income black 
areas due to overcrowding, poor health and sanitary conditions, and high rates of drug 



121 



abuse (Cherubin et al., 1972; Alter, 1983). Reducing the level of hepatitis by improving 
living conditions and medical care, and reducing the population of drug abusers may 
thus be important for intervening into the cycle of high rates of alcohol-related morbidity 
and mortality. 

Implications for Research 

Designing effective intervention and prevention strategies for health problems in 
a special population group requires a good knowledge base about the etiology of such 
problems in the particular population. For the most part, this kind of knowledge is 
lacking with reference to blacks. There are few in-depth studies which examine alcohol- 
related problems or diseases among blacks. Most existing analyses rely on studies with 
very small sub-samples of blacks or on data on blacks gleaned from aggregate statistics. 
Rarely do these studies provide enough information to understand the specific processes 
related to the development of alcohol-related problems. 

Three broad areas of research need to be greatly expanded in the black population. 
First, more clinical and epidemiological studies on alcohol-related diseases need to be 
conducted. These studies are needed to provide insight into the contribution of eilcohol 
consumption and other risk factors for disease. Establishing relative risks for 
consumption is important for determining safe levels of alcohol beverage use. 
Intervention strategies based on this kind of knowledge may be much more effective 
than the vague references to "moderate drinking" which are common in alcohol education 
campaigns. 

Second, research data on blacks from alcohol problems reporting systems needs 
to be made more available. Although data on race and ethnicity may be collected in 
these systems, they are often omitted when the data are reported or analyzed. More 
complete data on the racial breakdown of alcohol-related accidents, suicides, treatment 
and hospitalization, and related topics are needed to assess the magnitude of black 
alcohol problems and plan interventions. 

Third, much more research on the social and cultural factors influencing black 
drinking should be implemented. For example, the issue of age of transition into heavy 
drinking is a key problem in the literature on black drinking. Currently, blacks in 
early middle-age appear to be at high risk for social problems related to alcohol use. 
However it is not known whether this pattern is related to specific socialization or 
maturational features in black culture which delay age of drinking, or to "cohort effects" 
or historical events which make blacks in this age group more vulnerable to drinking. 
If this phenomenon is more related to cohort effects than to maturational differences 
in drinking, it may mean that high rates of heavy drinking will persist in the older age 
groups as this cohort ages. Knowledge about the social factors which influence age 
of drinking and patterns of socialization to drinking thus hold implications for the 
populations and the social forces to be addressed in intervention measures. 

A related concern regarding the transition into heavy drinking involves the 
question of why blacks in alcoholism treatment are so much younger than whites. In 
contrast to the youthfulness of blacks in alcoholism treatment, numerous studies showed 
that black youth in the general population are, on the whole, at much lower risk for 
drinking, drunkenness, and arrests for alcohol-related offenses. Examining this issue 
has important implications for determining which youth populations are at risk for 
developing alcohol problems and designing appropriate strategies for intervention. 



122 



The drinking practices of black women are another major area of concern which 
has been little explored in the literature. Given the apparent polarization of female 
drinking patterns, and low ratio of male to female alcohol problems, research is needed 
to ascertain the socio-cultural factors associated with heavy drinking among black 
women. The special problems of intervening and responding to problems among women 
should also be addressed since the current literature is heavily biased toward male 
drinkers. 

Finally, more knowledge is needed about black cultural values and social norms 
regarding alcohol consumption, alcohol problems, and health behavior in general. Prior 
studies have suggested that blacks' attitudes towards alcohol consumption are polarized 
and ambiguous. The implications of these findings for explaining drinking patterns, 
rates of alcohol problems, and community responses to problems need to be explored 
in greater detail. This knowledge can be used to formulate intervention strategies 
which are culturally appropriate and relate to the perceived needs of the black 
community. 



123 



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132 



APPENDIX 



133 



Table! 

U.S. AGE-SPECIFIC DEATH RATES** FOR CIRRHOSIS OF LIVER 
BY RACE AND SEX: ALL DEATH REGISTRATION STATES 1910-1978 

ALL RACES, BOTH SEXES; 1910-1978 







25-34 


35-44 


45-54 


55-64 


65-74 


75-84 


85 Tctrt 


rE*« 


TOTAL 


Te«r5 


r»«rt 


Ittrt 


1ttr% 


r»«rt 


Te«rt 


ind Over 


1978 


13.8 


3.5 


14.4 


32.1 


43.5 


41.6 


30.8 


18.0 


1977 


14.3 


3.8 


15.3 


33.8 


4S.4 


42.6 


10.2 




1976 


14.7 


3.7 


16.9 


35.0 


47.6 


42.6 


29.3 




197S 


14.8 


3.8 


15.7 


36.0 


49.0 


42.8 


29.0 




197* 


15.8 


4.2 


18.6 


38.7 


50.9 


45.9 


29.5 




1973 


15.9 


4.2 


19.4 


39.1 


52.5 


44.6 


26.8 




1972 


15.6 


4.3 


20.3 


38.9 


50.3 


43.1 


29.5 




1971 


15.4 


4.2 


19.4 


38.4 


50.1 


43.4 


29.6 




1970 


15.5 


4.4 


19.6 


38.3 


49.3 


42.2 


30.9 




1969 


14.8 


4.3 


19.0 


36.5 


47.7 


40.9 


28.8 




1968 


14.6 


4.2 


18.1 


36.6 


46.7 


41.6 


28.8 




1967 


14.1 


4.0 


17.2 


34.8 


• ^.7 


41.1 


27.4 




1966 


13.6 


3.8 


16.6 


33.8 


43.3 


39.8 


29.8 




1965 


12.8 


3.5 


15.0 


31.9 


40.1 


38.0 


29.9 




1964 


12. 1 


3.3 


13.9 


29.5 


38.2 


36.8 


29.4 




1963 


11.9 


3.3 


12.7 


29.9 


36.4 


37.6 


29.5 




1962 


11.7 


3.2 


13.0 


28.9 


35.4 


37.1 


29.4 




1961 


11.3 


3.1 


12.3 


27.5 


34.2 


35.7 


30.1 




1960 


11.3 


2.9 


11.8 


27.6 


32.7 


37.4 


32.1 




19S9 


10.9 


2.8 


H.5 


26.1 


31.8 


34.9 


33.0 




19S8 


10.8 


2.5 


11.1 


24.9 


31.3 


36.6 


34.0 




19S7 


11.3 


2.9 


12.1 


25.6 


33.0 


38.2 


35.3 




19S6 


10.7 


2.4 


11.2 


23.8 


30.9 


36.8 


37.3 




19SS 


10.2 


2.1 


10.5 


22.8 


28.8 


36.1 


35.9 




19S« 


10.1 


2.2 


10.4 


21.5 


29.1 


35.5 


35.7 




1953 


10.4 


2.3 


10.7 


23.0 


29.9 


34.7 


38.8 




1952 


10.2 


2.4 


10.6 


22.4 


29.9 


34.1 


37.6 




1951, 


9.8 


2.3 


10.1 


21.1 


28.7 


34.0 


38.7 




1950' 


9.2 


2.1 


9.3 


19.1 


27.2 


33.8 


36.9 




1949 


9.2 


2.1 


9.4 


18.9 


28.3 


31.9 


38.3 




1948 


11.3 


2.4 


11.0 


23.3 


33.5 


40.8 


52.9 




1947 


10.4 


2.1 


9.6 


20.6 


31.1 


39.5 


52.9 




1946 


9.6 


2.1 


9.0 


18.7 


28.5 


36.3 


49.2 




1545 


9.5 


2.2 


8.5 


18.1 


27.0 


35.7 


44.9 




1944 


8.6 


2.0 


7.1 


15.3 


26.3 


35.6 


47.8 




1943 


9.3 


1.9 


7.8 


18.0 


28.5 


39.8 


52.0 




1942 


9.4 


2.1 


8.5 


18.5 


29.1 


39.2 


52.0 




1941 


8.9 


2.1 


7.8 


17.6 


27.7 


39.9 


48.8 




1940 


8.6 


1.8 


7.2 


16.5 


27.8 


39.2 


51.8 




1939 


8.3 


1.7 


6.6 


15.5 


27.8 


40.3 


55.6 




1938 


8.3 


1.7 


6.9 


16.2 


27.1 


40.7 


58.3 




1937 


8. 5 


1.7 


7.2 


17.0 


28.3 


41.3 


59.4 




1936 


8.3 


1.7 


7.1 


15.8 


28.8 


41.6 


57.7 




1935 


7.9 


1.6 


6.4 


15.7 


27.3 


41.5 


60.2 




1934 


7.7 


1.8 


6.4 


15.1 


27.2 


40.4 


60.1 




1933 


7.4 


1.6 


5.9 


14.3 


26.9 


41.9 


59. 9 




1932 


7.2 


1.4 


5.7 


14.0 


26.1 


41.2 


58.4 




1931 


7.4 


1.7 


5.9 


14.8 


26.8 


«:.; 


59.4 




1930 


7.2 


1.5 


6.1 


14.0 


26.8 


«3 


57.5 




1929 


7.2 


1.5 


6.3 


14.5 


26.1 


43.8 


57.1 




1928 


7.5 


1.6 


6.4 


15.0 


27.7 


46.3 


63.6 




1927 


7.4 


1.5 


5.9 


14.4 


26.7 


48.8 


66.6 




1926 


7.2 


1.6 


5.6 


13.7 


27.8 


44.0 


71.2 




1925 


7.2 


1.4 


5.8 


14.1 


27.5 


46.1 


71.7 




1924 


7.3 


1.5 


5.2 


15.3 


27.1 


50.2 


64.8 




1923 


7.1 


1.2 


4.9 


14.0 


27.5 


49.7 


73.1 




1922 


7.4 


1.4 


5.1 


13.7 


28.9 


52.8 


78.8 




1921 


7.3 


1.4 


4.4 


13.2 


29.9 


54.4 


78.8 




1920 


7.1 


1.3 


4.5 


12.9 


28.1 


53.2 


78.2 




1919 


7.9 


1.4 


5.8 


15.4 


34.4 


55.3 


83.7 




1918 


9.6 


2.4 


8.5 


19.2 


38.4 


60.9 


80.9 




1917 


10.9 


2.7 


10.3 


24.6 


43.2 


66.9 


90.6 




1916 


11.8 


3.7 


11.9 


25.8 


48.1 


70.3 


89.2 




1915 


12.1 


3.5 


12.2 


26.7 


46.7 


73.1 


90.6 




1914 


12.'. 


3.6 


13.3 


29.5 


45.1 


76.9 


95.2 




1913 


12.9 


3.3 


14.3 


30.0 


49.5 


SO.l 


86. S 




1912 


13.1 


3.9 


14.0 


29.7 


53.2 


78.8 


94.0 




1911 


13.6 


4.3 


14.4 


32.5 


52.6 


82. 8 


100.0 




1910 


13.3 


4.3 


14.7 


31.4 


54.2 


77.0 


86.6 





•• 0««Ul rlttJ ir» Mr 100.000 r«t4»nt popuUtion for 10«tflea qroupj. 

B<s*4 on cnmrtced popuUcton tdjiaced for «9t 6Us In tKt populttlon o' races othtr than Khlt*. 



Source: Malin, et al (1980) 

134 



Table 2: U.S. Arrest Rates for Drunkenness, Per 100,000 Population, 

Persons Age 18 Years and Over, By Race, 

1965-1982 



Year Blacks Whites 

1965 271^1.9 9^9.3 

1966 2it30.tt- 922.7 

1967 2650.9 917.^ 

1968 2215.2 8^9.8 

1969 2192.^* 8^1.3 

1970 2192.1 872.3 

1971 2085.9 Si^lA 

1972 2005.0 778.5 

1973 1717.'f 666.2 
197'f 1261.2 W9.2 

1975 l'f88.'f 652.9 

1976 1330.6 593.9 

1977 1355.1 672.8 

1978 1231.1 615.3 

1979 1085.0 603.^^ 

1980 9^*8.7 570.8 

1981 928.7 592.2 

1982 885.9 557.0 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, ^16, 'f^l, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the population base for 
black females included non-whites. 



135 



Table 3: U.S. Arrest Rates for Driving Under the Influence, Per 100,000 Population, 

Persons Age 18 Years and Over, By Race, 
1965-1982 



Year Blacks Whites 

1965 303.5 168.6 

1966 330.6 175.9 

1967 395.6 190.4 

1968 386.6 207.1 

1969 itiiZ.3 231.7 

1970 509.3 262.'f 

1971 580.5 295.8 

1972 700.5 380.1 

1973 711.7 408.7 

1974 617.6 382.0 

1975 781.9 567.0 

1976 755.1 505.8 

1977 902.8 672.3 

1978 916.6 701.5 

1979 910.3 737.9 

1980 829.4 767.7 

1981 884.8 831.8 

1982 813.4 808.2 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, 416, 441, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the population base for 
black females included non-whites. 



136 



Table *: U.S. Arrest Rates for Liquor Laws Violation, Per 100,000 Population, 

Persons 18 Years and Over, By Race, 
1965-1982 



Year Blacks Whites 

1965 231.0 80.3 

1966 202.6 89.5 

1967 21^.7 95.3 

1968 163.2 98.8 

1969 167.8 96.5 

1970 139.5 88.^* 

1971 1^*3.6 89.6 

1972 1^5.6 Si^A 

1973 126.0 68.6 
197'f 10^.1 71.7 

1975 125.7 103.0 

1976 163.^^ 120.if 

1977 l'f5.6 126.7 

1978 l^'f.6 1^3.5 

1979 13't.3 155.0 

1980 liH.7 179.6 

1981 172.^ 192.0 

1982 18^^.6 166.2 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, ^16, 't^l, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the papulation base for 
black females included non-whites. 



137 



Table 5: U.S. Arrest Rates for Drunkenness, Per 100,000 Population, 

Persons Under Age 18 Years By Race, 

1965-1982 



Year Blacks Whites 



1965 


31.2 


35.0 


1966 


30.0 


^^0.7 


1967 


^1.3 


^6.1 


1968 


39.6 


50.5 


1969 


38.7 


59.9 


1970 


^^6.2 


5i*.2 


1971 


t^l.3 


59.3 


1972 


37.2 


57.9 


1973 


26.2 


52.3 


197't 


18.7 


t^t.5 


1975 


26.7 


66.3 


1976 


26.6 


65.6 


1977 


30.3 


85.5 


1978 


26.3 


75.2 


1979 


25.8 


81.6 


1980 


20.6 


75.3 


1981 


18.3 


67.3 


1982 


17.9 


60.7 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, ^16, t^ttl, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the population base for 
black females included non-whites. 



138 



Table 6: U.S. Arrest Rates for Driving Under the Influence, Per 100,000 Population, 

Persons Under 18 Years, By Race, 
1965-1982 



Year Blacks Whites 



1965 


1.2 


2.8 


1966 


1.2 


3.5 


1967 


1.9 


if.2 


1968 


2.3. 


it.7 


1969 


2.8 


5.8 


1970 


3A 


6.6 


1971 


3.2 


8.0 


1972 


*.2 


11.7 


1973 . 


HA 


l'f.3 


1974 


3.7 


14.3 


1975 


6.5 


28.4 


1976 


6.1 


29.4 


1977 


9.2 


43.1 


1978 


9.6 


47.9 


1979 


IC^f 


54.8 


1980 


8.0 


54.4 


1981 


7.3 


52.5 


1982 


7.2 


46.8 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, 416, 441, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the population base for 
black females included non-whites. 



139 



Table 7: U.S. Arrest Rates for Liquor Laws Violation, Per 100,000 Population, 

Persons Under 18 Years, By Race, 
1965-1982 



Year Blacks Whites 



1965 


23.0 


70.9 


1966 


21.'* 


85.3 


1967 


27.3 


95A 


1968 


22.6 


103.* 


1969 


23.8 


110.5 


1970 


27.8 


106.6 


1971 


27.7 


119.* 


1972 


25.8 


122.7 


1973 


22.1 


122.0 


197^* 


20.6 


131.3 


1975 


27.3 


179.3 


1976 


33.3 


187.3 


1977 


29.0 


211.* 


1978 


29.8 


229.5 


1979 


33.9 


257.3 


1980 


32.^ 


259.0 


1981 


37.^* 


25*.2 


1982 


*1.3 


218.8 



Source: Arrest Statistics — Uniform Crime Reports, Federal Bureau of Investigation, 

1965-1982. 

Population Data ~ Current Population Reports, Series P-25, Nos. 321, 352, 

385, *16, **1, 721, 870, 929. 

Note: For years 1965 and 1966 the population base for blacks was the "non- 
white" population. For years 1968 and 1969 the population base for 
black females included non-whites. 



140 



Patterns and Problems of 



Dependency 



Drinking Among U.S. 
Hispanics 




Raul Caetano, M.D., Ph.D. 

Alcohol Research Group 

Institute of Epidemiology and Behavioral Medicine 
Medical Research Institute of San Francisco 
Berkeley, California 



Introduction 

Drinking and alcohol-related problems are patterned by a number of characteristics 
of the user. Men drink more than women, the young drink more than the old, in the 
U.S. northeners drink more than southeners. Cultural norms and values associated with 
different ethnic groups in the U.S. also influence alcohol use and the level of alcohol 
problems in these groups. Alcohol research has paid considerable attention to the way 
in which these cultural traditions shape drinking behavior and there are by now many 
papers describing the relationship between ethnicity and alcohol consumption. This 
body of research contains overwelming evidence attesting to the many ways in which 
drinking practices are shaped by folkways. However, most of the available evidence 
describes alcohol use among Jews Italians and Irish-Americans (Bales, 19't6, 1962; 
Snyder, 1958; LoUi, 1958; Knupfer and Room, 1967). 

In contrast to the amount of available information regarding drinking by these 
American ethnic groups, little is known about alcohol use and the prevalence of alcohol 
problems among Hispanics in the U.S. The available data suggest that this ethnic group 
has a high proportion of heavy drinkers, drunkenness and alcohol-related problems and 
that as such Hispanics should be singled out as a target group for prevention interventions 
(Cahalan and Room, 197^; Caetano, 198^a, 198'fb). However, the design of effective 
prevention strategies requires the identification of specific target groups as defined by, 
for instance, major sociodemographic characteristics as well as the identification of 
specific problems to be prevented. This is especially true of U.S. Hispanics, who form 
a very hetergeneous group with people from various nationalities and with different 
social and cultural backgrounds. 

As a whole Hispanics comprise 6% of the American population. Mexican- 
Americans are in majority, constituting 60% of all Hispanics. Puerto Ricans comprise 
another 15%, Cuban- Americans, 6%, and "other" Hispanics 20% (Bureau of the Census, 
1981). Perhaps the most marked contrast among these groups in terms of socioeconomic 
status and migration history occurs between Cubans and Mexican-Americans. The first 
wave of Cuban immigration to the U.S. occurred mainly because of political reasons 
and the immigrants were mostly of middle-clciss background. Subsequent immigrants 
have a more mixed class background and have also come for economic reasons. Mexican- 
Americans have been coming to the U.S. mostly for economic reasons, and are from 
the lower socioeconomic stratum of rural and urban areas of Mexico. Puerto Ricans 
also come to the U.S. for economic reasons and are, at least in this respect, closer 
to Mexican-Americans than to Cubans. The "other" Hispanic group is difficult to 
characterize. It is formed by people who come from all the other countries of Central 
and South America. Some have come to the U.S because of political persecution. 
Others have come for economic reasons. They have diverse cultural origins, as can 
be exemplified by the case of Brazilians, who are sometimes included in this group but 
have a different language, different colonial history and markedly different cultural 
traditions from the rest of the people from South and Central America. The importance 
of this heterogeneity for research has been stressed (Hernandez et al., 1973; Hayes- 
Bautista, 1980; Aday et al., 1980). It should be kept in mind as the findings from 
alcohol research among Hispanics are examined, since results are always given for 
Hispanics as a whole as if this was a homogeneous group. 

This report examines the alcohol literature on U.S. Hispanics in hope that such 
review will provide enough information to recognize target groups and target problems 
for which specific prevention interventions can be proposed. With this objective in 
mind, this report was developed according to the following plan. The first section 
examines epidemiological data in the areas of mortality, traffic accidents, arrests, and 



143 



treatment for alcohol-related psychiatric conditions or alcoholism among Hispanics. The 
second section reviews studies of drinking patterns and prevalence of alcohol-related 
problems in the community. In this section special attention is given to the results of 
a recent analysis of eilcohol use and prevalence of problems among Hispanics living the 
San Francisco Bay Area. The final section presents the conclusions, suggests future 
lines for research and proposes policy and prevention strategies to minimize alcohol 
problems among U.S. Hispanics. 

Indirect Indicators of Alcohol-Related Problems: Mortality, Arrests, and Treatment for 
Alcohol-Related Problems 

Any attempt to portray alcohol-related problems among Hispanics in the U.S. 
with the use of indirect indicators will face considerable difficulty. The alcohol 
literature has very few examples of such attempts (Alcocer, 1979; Hall et al., 1977) 
and these do not cover more recent data. Official publications are incomplete with 
regard to their coverage of ethnicity, and they usually concentrate on social rather 
than health indicators. Griffith (1980) reports that updated coverage for this group at 
the national level is being implemented by a number of federal agencies in response 
to Public Law 9't-311. This law was passed on 3une 16, 1976 and mandates the 
Departments of Commerce, Agriculture, Labor, and Health, Education and Welfare to 
improve and expand statistical coverage for Hispanics in the U.S. The 1981 report 
from the F.B.I, on Crime in the United States reports nationwide statistics on alcohol- 
related crimes by persons of Hispanic origin for the first time and these data are 
discussed below (F.B.I., 1982). The future may bring other improvements to this 
situation. Meanwhile, the statistics below give some indication of the extent to which 
alcohol-related problems affect the Hispanic group. 

Mortality Data 

The association between alcohol intake and mortality is usually assessed by 
statistics on cirrhosis mortality, although other causes of death such as suicide, traffic 
fatalities, certain cancers of the upper digestive tract, and deaths with alcohol-related 
psychiatric diagnoses also hold a close association with heavy alcohol ingestio" However, 
alcohol-related mortality statistics offer a limited coverage of the Hispanic population 
in the U.S. Regular publications on mortality statistics for the U.S., for instance, do 
not recognize Hispanics as a racial or ethnic group. As a result, a search for mortality 
data for the U.S. as a whole on this ethnic group resulted in failure. Some of the 
available information comes from regional studies (usually in counties of states with 
large Hispanic populations) and therefore have limited applicability. Mortality statistics 
produced for the U.S. as a whole are still divided into White and Non-White, or into 
racial or ethnic groups such as Black, Indian, Chinese, Japanese. The existing literature 
- no more than a handful of papers - covers the Hispanic population of the Southwest, 
mostly Mexican-Americans living in Texas and California. Other reviewers have 
commented on these difficulties. In a recent report on general mortality among minority 
populations, Markides (1983) limited his discussion of research results to the experience 
of this same group of Hispanics in the Southwest, since this was the only group for 
which information was available. 

Edmandson (1975), for instance, reports findings from a study of autopsies 
performed at the University of Southern California's Medical Center in Los Angeles 
County. Analyzing data collected at several points in time between 1918 and 1970, 
he reports a sharp rise in alcohol-related deaths (no definition for alcohol-related is 
given) between 1950 and 1970 affecting all ethnic groups in the study. The increase 
for Mexican-Americans is the sharpest and alcohol-related deaths in this group rose 



144 



from approximately '*% of all autopsies in 1950 to 18% in 1970. Among Mexican- 
American men 30 to 60 years of age, this group of deaths is responsible for 52% of 
all deaths, and among Mexican- American women in the same age span for 20% of all 
deaths. Still in the same age group, the proportion for White men and White women 
is 2^% and 23%, respectively; for Black men it is 22% and for Black women, 21%. 
The increased rate of deaths associated with alcoholism among Mexican-Americans is 
confirmed in another study by Edmanson (1976, cited in Hall et al., 1977). Data on 
another series of autopsies covering the period from 1970 to 1976 shows that while 
the proportion of alcoholism deaths is 20% of all deaths in men and 10% of all deaths 
in women in the general population of California, among Mexican-American men the 
percentage is 26%, and among Mexican-American women 7%. Among other Whites the 
proportions are 19% in males and 12% in females. 

Taken together, the results reported by Edmandson suggest that the proportion 
of alcohol-related deaths in all deaths among Hispanics increcised rapidly from 1918 up 
to 1970 and declined thereafter. Whether these changes reflect reality or some artifact 
of methodology is difficult to say. The data for Edmandson's first series, 1918 to 
1970, come from testimony to the Subcommittee on Alcoholism of the State of California. 
This is not a formal paper and it does not give much information as to how the data 
were collected. Hall's discussion of the second series of autopsies, 1970 to 1976, does 
not provide information as to the comparability of data collection procedures and data 
analysis between the two studies. 

Moustafa and Weiss (1968, cited in S^hreiber and Homiak, 1981) report a cirrhosis 
death rate for Hispanics of San Antonio, Texas equal to 11/100,000 population, while 
the rate for Anglos was 9.7/100,000 population. Engmann (1976) reports on alcohol- 
related deaths (alcohol-dependence, alcohol psychosis, and cirrhosis of the liver attributed 
to alcohol) among Hispanics in California for the years 1970-197^. In this time span 
alcohol-related deaths for Hispanics varied from 1^*% of all alcohol-related deaths for 
all races in 1970 to 15% in 1971, to 1^.5% in 197^. Since the proportion of Hispanics 
in the state population weis 15% at the time, there is no overrepresentation of Hispanic 
among all alcohol-related deaths occurring in the state. When broken down by sex, 
Engmann's data show that Hispanic men are equally represented (15%) both among 
alcohol-related deaths which occurred between 1970 and 197^* and in the state's 
population of 1970. Hispanic women are underrepresented among those who died of 
alcohol-related deaths. Their rate ranged from 6.9% to 10.^*% between 1970 and 197^^, 
while according to the 1970 Census they comprised 15% of California's female population. 
When the alcohol-related deaths among Hispanics are examined by age, a greater 
proportion of the deaths in this population occur at younger ages than would be expected. 
In the general population, 3.7% of all alcohol-related deaths are in the 21-3f age group; 
among Hispanics the proportion is twice as high, 7A%. The 35-i^>t age group accounts 
for 19% of all alcohol-related deaths in the general population, while among Hispanics 
the proportion is 31%. 

Results of a study by Burns (1983) with mortality data for Los Angeles County 
confirm the Edmanson and Engmann findings. Areas of the county predominantly 
populated by Hispanics (Central Los Angeles and East Los Angeles-Highland Park) have 
the highest rates of alcohol-related mortalit" The relationship between alcohol use 
and problems is further confirmed by Burns in an analysis of the relationship between 
mortality and number of alcohol outlets available in the community. In West San 
Fernando Valley, an affluent area of the county predominatly populated by Whites, the 
alcohol-related mortality rate is 1.23 deaths per 10 000 population and there is one 
outlet per 871 residents. In Hispanic East Los Angeles, the death rate is almost three 
times higher, 3.1^*, and there is one outlet for every 500 residents. In Central Los 



145 



Angeles the death rate is even higher, 'f.SS/ 10,000 population, and there is one outlet 
per 400 residents. 

Finally, the association between alcoholism and violent death was studied by 
Haberman and Baden (1974) in a sample of 1,000 violent, sudden, medically unattended 
deaths in New York City. The deaths comprised those investigated by the city's Office 
of the Chief Medical Examiner from February 14 to April 11, 1972. Decedents were 
classified as alcoholics by means of information collected from relatives or by autopsy 
findings. Of the 1,000 decedents, 30% (297) were identified as alcoholics. Approximately 
9% of the sample (88 individuals) had been born in Puerto Rico and about 10% of those 
diagnosed as alcoholics had the same origin. 

Alcohol-Related Arrests 

Numerous studies have revealed higher arrest rates for drunk driving and public 
drunkenness than expected for Hispanics. May and Baker (1974) report a randomly 
selected sample of 200 traffic accidents which occurred between 1972 and 1973 in 
ernadillo County, New Mexico. Out of 4,000 alcohol-related accidents which occurred 
in 1972 and 1973, 200 were randomly selected for the study. The results show that 
Hispanic drivers are overrepresented. While Hispanics comprise 39% of the county's 
population, their percentage of accident drivers is 46%. Similar results are reported 
for Kern County, California (Kern County Department of Mental Health Services, 1974). 
While this ethnic group comprised 17% of the county's population, their proportion of 
those arrested for an alcohol offense was 28%. Alcocer (1979) also reports high rates 
of alcohol-related arrests for areas of Los Angeles with predominantly Hispanic 
populations. Reviewing Los Angeles Police Department data for traffic accidents which 
resulted in injury or fatality, he found that while Anglo neighborhoods have rates of 
.92%, areas where Hispanics are a majority have rates of 1.32%. The rate for drunk 
driving arrests (felony and misdemeanor) in the Hispanic area is 1.3%, against .91% 
and .71% for Anglo areas. Speiglman (1984) analyzing 1979 data on alcohol-related 
arrests in Fresno County, California, informs us that Hispanics (mainly Mexican- 
Americans) comprised 60% of all persons arrested for public drunkenness while their 
proportion in the county population according to the 1980 Census was 30%. 

Examining data for California, Engmann (1976) reports that in 1974 Hispanics 
accounted for 21% of all arrests for drunk driving and for 27% of all arrests for public 
drunkenness. Once again they are overrepresented, since the proportion of the state's 
population identified as belonging to this ethnic group was not more than 16% at that 
time. Statewide data on alcohol-related arrests in California during 1980, as reported 
by the state's Department of Justice (1980), confirms Engmmann's findings About 33% 
of those arrested for drunkenness and 28% of those arrested for drunk driving are 
Hispanics compared to 19% of those in the state's population. Among those arrested 
for public drunkenness, the Hispanic group comprises twice their share of the population, 
while among those arrested for drunk driving 1.8 times their share. 

National data on alcohol-related arrests as reported by the F.B.I. confirm the 
higher rate of arrests among Hispanics when compared to non-Hispanics (F ~ .1., 1982). 
Arrests for driving under the influence, liquor law offenses and drunkenness are the 
source of 43% of all arrests among Hispanics 18 years of age and older, while in the 
non-Hispanic group this proportion is 33% (Table 1). The proportion of all arrests 
represented by arrests for driving under the influence and liquor law violations is similar 
for Hispanics and non-Hispanics, but Hispanics are twice as likely to be arrested for 



146 



drunkenness as non-Hispanics. Among those 18 years of age and older, arrest rates 1 
for driving under the influence are twice as high among Hispanics cis among non- 
Hispanics (Table 2). Arrest rates for drunkenness are three and a half times higher 
for Hispanics than for non-Hispanics. In group under 18 years of age the largest 
difference between the two groups in Table 2 is for the arrest rate for drunkenness: 
Hispanics have a rate which is almost four times higher than that for non-Hispanics. 
Rates for DUI are similar between the two groups, while arrest rates for liquor law 
violations are higher among non-Hispanics than Hispanics. 

However, there is controversy over whether the overrepresentation of Hispanic 
individuals among drunk driving arrests represents a greater prevalence of drunk driving 
behavior or police bias against this ethnic group. Morales (1970) studied alcohol-related 
arrests in two areas of Los Angeles: Ecist Los Angeles, which is 50% to 60% Hispanic, 
and West Valley, which is 95% Anglo in population. Although these two areas have 
approximately the same population ~ 260,000 inhabitants ~ East Los Angeles had 6 
times more alcohol-related arrests (9,676 versus 1,552) in 1968. Morales charges that 
such differences do not arise from high levels of alcohol consumption by the Ecist Los 
Angeles population but from differences in police enforcement of alcohol-related laws 
in the two areas. According to him, although East Los Angeles heis half the square 
mileage of the West Valley (26 versus 5^) and the same major crime rate {IA% versus 
1.3%), it has four times more police officers per square mile (13.5 versus 3.5). 

Contrary to Morales, Hyman (1968) and Hyman et al. (1972) in their study of 
drunk driving arrests in Santa Clara County, California, and Columbus Ohio report that 
they could not find evidence of police discrimination against Hispanics. In Santa Clara 
County the proportion of Hispanic men among those arrested for drunk driving in a 6 
month time span in 1962 was 21%, or twice the proportion of Hispanics in the county's 
population in the 1960 Census. According to Hyman et al. (1972) police bias would be 
present if a large proportion of Hispanics arrested had a lower blood alcohol concentration 
or a lower rate of accident involvement than "Others" arrested. This was not the 
case. Hispanics had the same level of blood alcohol concentration as the "Others" and 
had higher rates of accident involvement than Whites, ^^0% versus 30%. Hyman's 
conclusion is based on the assumption that a similar distribution of BAL results for 
Hispanics and other groups would indicate that police enforcement of drunk driving 
laws affects all the groups studied equally. This cissumption, however, does not take 
into account a scenario where police enforcement would be unbiased but police 
surveillance would not. That is, while enforcing drunk driving laws equally across ethnic 
groups police could still have a higher number of offices patrolling Hispanic 
neighborhoods. Also contradicting Morales is Gordon's (1979) report of apparent police 
tolerance of drunk driving and public drunkenness in a Hispanic neighborhood. This 
account comes from Gordon's experience of law enforcement in a New England city 
with a large Hispanic community, most of whom had come from Santo Domingo. 

In New Haven, and contrary to what seems to be a California experience, Abad 
and Suarez (197^^) reveal that Puerto Ricans are underrepresented among the alcohol- 



1. Population denominators for these rates were taken from the 1980 Census (Bureau 
of the Census, 1981). The base for the rates among those less than 18 years of age 
should use the population 13 to 17 years old. This is the population responsible for 
most the offenses in this age group. However, census figures for Hispanics can only 
be grouped for those 10 to 19 years of age, and this is the denominator used in the 
calculation. 



147 



related arrests. Thus, of the 3,600 arrests for public intoxication in 1971, only ^.7% 
were Puerto Ricans, while their representation in the population was 8.7%. 

Admission for Alcoholism Treatment 

The proportion of Hispanic persons receiving treatment for "alcoholism" varies 
according to the source of data, the type of facility being considered, and the region 
of the country. Until some years ago, data on alcohol-related admissions to mental 
hospitals were the primary indicators for studying the demographic characteristics of 
individuals in treatment. With the phasing out of the mental hospitals, and the 
development of a diversified system of treatment facilities for alcoholism other than 
psychiatric wards, these statistics became less valid. Some states, California for 
instance, stopped publishing statistics on alcohol-related admissions to psychiatric 
hospitals altogether, since the proportion of individuals receiving, treatment with such 
diagnoses has been minimal in the last 10 years (Cameron, 1981). 

However, some recent U.S. government special publications have analyzed these 
kind of data with reference to minority groups. Table 3 shows admissions with drug 
and alcohol-related disorders in different types of psychiatric facilities for the year of 
1975 (American Public Health Association, 1982). The proportion of Hispanic individuals 
in treatment varies dramatically according to the facility under consideration. It is 
as low as 6% in outpatient services, but rises to seven times that in State and County 
mental hospitals. When compared to Whites and Blacks, there seems to be a 
concentration of Hispanic persons both in these latter type of institutions and in private 
mental hospitals. Why there should be more Hispanics than Whites in private mental 
hospitals is difficult to explain. The contrary would be expected because of the 
differences in socioeconomic status between these two groups. It is quite possible, 
however, that the difference stems from the type of facilities covered by the data in 
the table. 

A more recent and more specific indicator of clients receiving treatment for 
alcoholism are the data depicted in Table ^t. The information comes from the State 
Alcoholism Profile Information System - and was collected by the National Drug and 
Alcoholism Treatment Utilization Surveys ~ NDATUS (SAPIS, 1981; Department of 
Health and Human Services, 1983). This is a cooperative federal-state program for 
collecting information on cases treated in publicly supported treatment facilities. The 
data in this Table were collected in two point prevalence surveys two years apart, 
September 30, 1980 and 1982. States in the Table are those known to have a large 
percentage of Hispanic individuals in their population. In 1980, the proportion of 
Hispanic persons in treatment ranges from 5% in Florida to 35% in New Mexico In 
Arizona, Florida, and New Mexico this ethnic group is underrepresented among the 
client"! In all the other states Hispanics are overrepresented. Such overrepresentation 
is slight in Texas (difference of 2%), a little larger in New York (difference of it%) 
and California (difference of ^%), and very large in Colorado. In this latter state the 
Hispanic group comprises 12% of the State's population but their proportion in the 
treatment group is twice that. In the Southwest as a whole (Arizona, California, 
Colorado, New Mexico, Texas), the Hispanic group is overrepresented among those in 
treatment by 3 percentage points over their proportion in the regional population. For 
the U.S. the difference is larger: the proportion of Hispanics in treatment is substantially 
greater than their representation in the population. Data for 1982 do not vary a great 
deal from that for 1980. There is a slight decrease in the proportion of Hispanics in 
treatment in Colorado and Texas and an increase in New Mexico. 

In California the proportion of Hispanic persons in treatment varies accordng to 
the type of facility. According to the California Department of Alcohol and Drug 



148 



Programs (198^), on a typical day of fiscal year 1980-1981 Hispanics comprised 17% of 
the patients in privately funded treatment programs, 25% of those in publicly funded 
programs, 26% of those in drink driving programs and 13% of those in all other programs. 
Regarding their representation in the state population, 19%, Hispanics are thus 
overrepresented both in publicly supported programs and among participants in drinking 
driving programs. 

Community Surveys of Drinking Patterns and Alcohol-Related Problems 

The first survey of alcohol use and alcohol-related problems to present data on 
the Hispanic group is that by Cahalan et al. (1969). Respondents constituted a probability 
sample representative of the U.S. population 21 years and older. Among those 
interviewed there were 58 individuals who identified themselves as "Latin American, 
Caribbean". The rate of abstention in this group is 37%, higher than the 32% of the 
total sample. There are fewer infrequent, light, and moderate drinkers among Latin 
Americans than among the total sample but more heavy drinkers (19% versus 12%). 
When Cahalan calculated the percentage of drinkers that belonged in the heavy drinker 
category, he found that 30% of the Latin Americans were thus recognized, the highest 
proportion of all national groups in his sample and 1.5 times more than the total sample 
(30% versus 18%). 

Cahalan and Treiman (1976) also report a high rate of abstention and occasional 
drinking (62%) among 80 "Latinos" in San Francisco, but they did not find a high rate 
of heavy drinking. Respondents in this study comprised a representative sample of San 
Francisco residents 12 years of age and older, and the data were collected through a 
meiil survey. Their rates of frequent heavy drinking or frequent high maximum intake 
are lower than those for Whites (^% and 6%, respectively), higher than those for Asians 
and Blacks, and similar to those for 3ews.2 With regard to the total sample. Latinos 
have a higher proportion of combined abstaining, infrequent, and occasional drinkers 
(62% versus ^^2%), but lower rates of frequent heavier drinkers (^% versus 7%) and 
infrequent high maximum drinkers (6% versus 12%). 

Latinos have a distribution of alcohol problems similar to that of the total 
sample. They have less "high intake" drinking, that is, drinking high quantities frequently 
(169b versus 2^% for the total sample), less symptomatic drinking (12% versus 17%) 
and less loss of control (7% versus 11%)." They report slightly more binge drinking 
(5% versus 3%), more job problems {^% versus 2%), and more spouse problems (14% 



2. Cahalan and Treiman's definitions for these drinking categories were as follows: 
frequent heavier drinker: drinks nearly daily and drinks 't+ drinks a day at least 
times per week. 

frequent, high maximum: drinks nearly daily and drinks k+ drinks a day at least monthly. 

frequent, low maximum: drinks nearly daily but not 'f+ drinks on any day during month. 

less frequent, high maximum: drinks 1-* days a week and drinks 't+ drinks at least once 

a month. 

less frequent, low maximum: drinks l-'t days a week but does not drink 't+ drinks on 

any day during the month. 

occasional, infrequent or abstainer: drinks on 1-3 days a month, or less than monthly, 

or never. 

3. Considered present when the respondent reported one or more of the following as 
present during the previous year: drinking first thing in the morning, having several 
drinks before a party, sneaking drinks, drinking more when alone, drinking to shake-off 
a hangover, unable to remember events that happened during the previous night. 



149 



versus 10%). The rates for police problems, health problems, and alcohol-related 
accidents are approximately the same as those for the total sample. 

Cahalan (1976) reports on a representative sample of adults residing in California 
of whom 61 identified themselves as "Chicanes". Results for this survey do not agree 
with those reported by Cahalan and Treiman (1976) for San Francisco. This is possibly 
due to a change in the definitions of the quantity-frequency categories employed to 
describe drinking patterns, to differences in the ethnic composition of Hispanics in 
these two studies (most Hispanics in San Francisco are of Central American origin 
while in other parts of California they are mostly Mexican-Americans) and to real 
differences in drinking habits between San Francisco and California cis a whole.'* Thus, 
while Latinos in San Francisco have a higher proportion of infrequent drinkers, occeisional 
drinkers and abstainers than the total sample (62% versus ^-2%), in the statewide survey 
the situation is reversed. About 28% of the Chicanos are classified as "infrequent 
drinkers or abstainers", against 37% of the total sample. Other differences appear in 
the "frequent high maximum" category. In San Francisco Latinos have half as many 
drinkers in this category as the total sample (6% versus 12%), while in California 
Chicanos have more drinkers than the total sample (30% versus 20%). 

This California survey also shows striking differences between drinking patterns 
of men and women in the Chicano group. While 3% of the women are classified as 
frequent heavy drinkers, this category includes 13% of the men. Men also have a 
higher number of frequent high maximum drinkers than women, i*3% versus 16%. Women 
are concentrated in the infrequent low maximum, infrequent, and abstainer categories. 
Combined, these three categories include ^^9% of all the women but only 13% of the men. 

Finally, Chicanos in the California survey report more alcohol-related problems 
than the total sample in the following areas: friendship and social life, 7% versus 3%; 
marriage and home life, 12% versus ^%. Chicanos have fewer problems in the health 
area (3% versus 6%) and about the same proportion as the total sample in the work 
and financial position area (3% versus 2%). Chicano women report very few problems, 
and the differences between this ethnic group and the others stems from the high rate 
of problems among Chicano men, especially in the areas of "friendship and social life" 
and "marriage and home life". In the first area, 13% of the Chicano men report 
problems, against 'f% of the males in the total sample. In the second area the prevalence 
of problems among Chicano men is 20%, while among all males in the sample it is 7%. 

Alcocer (1979) reports one of the few alcohol studies in the U.S. specifically 
carried out to study drinking habits of Hispanics. Three communities in California 
were surveyed: East Los Angeles Montebello, East San Jose in Santa Clara County, 
and the cities of Huron, Mendota and Orange Cove in Fresno County. Respondents 
were randomly selected from the population 18 years old and over for inclusion in the 
survey. However, changes in the sampling process and additional interviewing may 



>*. Quantity-frequency categories were defined as follows for this California survey: 

frequent, heavier drinkers: 5+ drinks at least once a week. 

frequent, high maximum: drinks every week, sometimes 5 or more drinks. 

frequent, low maximum: drinks every week but never as many as 5 drinks per occasion. 

infrequent, high maximum: drinks less than weekly, sometimes 5 or more drinks per 

occasion. 

infrequent, low maximum: drinks less than weekly, never 5 or more drinks. 

infrequent: drinks less than once a month. 

abstainer: had not drunk alcohol in last year. 



150 



have compromised the randomness of the sample, especially in San 3ose and East Los 
Angeles Montebello. These considerations on sample representativeness are important 
due to the striking differences between some of Alcocer's results and those reported 
by Cahalan et al. (197't) for California. To facilitate comparisons between these two 
surveys Alcocer's respondents were grouped together by the present author, achieving 
an N of 603. However, the overall differences still hold when each of his communities 
is separately compared to Cahalan' s findings. 

While using the same measures of alcohol consumption applied by Cahalan, the 
rates of abstention and infrequent drinking in Alcocer's data are 3^% and 2^%, 
respectively.5 These rates are twice as high as those in Cahalan' s survey. However, 
when we look at the two topmost categories of the drinking typology (frequent heavier 
drinker plus frequent high maximum), Cahalan's data show twice as high a proportion 
as Alcocer's, 38% versus 20%. This difference occurs not so much because of the 
proportion of drinkers in the frequent heavier category (Cahalan, 8%; Alcocer, 6%) but 
more because of the difference in the proportion of frequent high maximum drinkers. 
Cahalan finds 30% of his drinkers in this category, while Alcocer has half that, or 
1^^%. When the data are broken down by sex, the differences between these two studies 
remain. 

When broken down by sex and locale, Alcocer's data show important differences. 
Women have a high proportion of abstainers and infrequent drinkers. This is especially 
so in Fresno, where approximately 80% of the women are in these two categories. The 
rate for East Los Angeles is also very high at 66%. Among males abstention rates 
are much lower, ranging from 2^1% in East Los Angeles to 12% in East San 3ose; 
Fresno has 17%. A large proportion of men are in the two highest categories of 
drinking (frequent heavy drinking and frequent high maximum). In East Los Angeles 
the rates of these combined categories is 39%; in Ecist San Jose it is ^^3%; and in Fresno 
it is ^^7%. 

When combined, Alcocer's samples show remarkably consistent rates for all type 
of problems. A toted of 10 areeis are examined in the study: a physician saying the 
respondent's drinking is harmful, accidents, drunk driving, trouble with the law, trouble 
with friendships, health problems, marriage problems, being afraid of becoming an 
alcoholic, being afraid of losing control, feeling that one should stop but could not. 
The rates vary from 7% (health problems) to 5% (harmful to friendship). Women have 
very few problems, with a rate ranging from 1% to 3%. Rates for men are much 
higher, varying from 10% to 1^%. When problem rates are broken down by sex within 
community, the following picture emerges: men in San Jose are more liable to report 
drinking problems than men in East Los Angeles and Fresno; the problem rate among 
women is very low across all communities, and no inter community distinctions seem 
to emerge. The variation of rates for men and uniformity for women may have been 
caused by sample variation, since the number of respondents in each sex group and 
locale was small, ranging from 130 to 70. 

A detailed study of drinking problems in a sample of men 21 to 59 years of age 
is reported by Cahalan and Room (197^*). The data come from two U.S. national 
samples and from a survey done in San Francisco, which is analyzed separately. In 
the national data a total of 1561 men were interviewed, of which 'f2 were identified as 
of "Latin American/Caribbean" ancestry. This group has the highest rate of problems 
(^3% of the group has high consequences of drinking) among all the ethnoreligious 



5. The typology is described in footnote ^. 



151 



groups studied. Cahalan and Room suggest caution when interpreting this result since 
the clustering sample technique used to combine the national samples does not guarantee 
representativeness, especially for small and highly segregated groups like Latin 
Americans/Caribbeans. The high rate of alcohol problems among Latin Americans could 
also be explained by some of the socio-demographic characteristics of this group, such 
as rate of work-instability and low socio-economic status. However, using multiple 
regression and automatic interaction detection techniques (AID), Cahalan and Room 
were able to confirm Latin American ancestry as an important predictor of problem 
drinking. This was especially so when the analysis wcis extended to predicting a high 
rate of problems among those with a high rate of alcohol intake. 

There were 786 men 21 to 50 years of age in the San Francisco survey analyzed 
by these authors. Of these, 96 were grouped under the "Latin American" heading by 
having indicated that most of their ancestors had come from these countries. This 
group of Latin Americans residing in San Francisco has a high rate of heavy alcohol 
intake (18%) and a high rate of binge drinking (10%) when compared to other ethnic 
groups. However, in the areas of symptomatic drinking and problems with police, work, 
and marriage, their rate is not very different from that found for the other ethnic 
groups nor from the San Francisco average. To explain this contreist between the rate 
of alcohol problems for Latin Americans in the San Francisco and the national samples, 
Cahalan and Room underline differences in sample composition. Thus, the Latin 
American group in the national sample is basically composed of men of Puerto Rican 
or Mexican ancestry, while in San Francisco there is a high percentage of Central 
Americans together with Mexicans. 

Difference in sample composition is only one of the factors hampering comparisons 
across the surveys mentioned so far. The data collection instruments, the drinker 
typologies and the problem definitions also change from study to study. Contrasts in 
problem rates such as those summarized in Table 5 might well be artifacts of these 
methodological differences. In the Table the only recognizable pattern is the uniformity 
of rates across problems shown in Alcocer's data when his three samples are combined. 

Cahalan and Cisin (1975), Cahalan (1970), Haberman (1970), and Haberman and 
Scheinberg (1967) also report rates of alcohol problems higher than average for Hispanics. 
Cahalan and Cisin (1975) describe drinking practices and problems of naval personnel. 
Among the enlisted men there were a group of 5't "Mexican-American/Chicanos". Their 
rate of alcohol problems (as defined by the presence of at least one serious consequence 
to interpersonal relationships or health) is 26%. This rate is four times higher than 
that for "Orientals", 2.5 times higher than that for "Blacks/Negro/Afro-American", and 
1.3 times higher than that for "White/Caucasian". 

Cahalan (1970) reports on a small group of 2^* Hispanics taken from a reinterview 
of the national sample of respondents 21 years and older first described in Cahalan et 
al. (1969). This group shows one of the highest rates of social consequences of drinking 
(problems in areas such as marriage, police, work, friendship, relatives). Habermcin 
(1970) and Haberman and Sheinberg's (1967) study is a survey of drinking practices of 
a representative sample (N=706) of New York City adults. The Puerto Rican group, 
as identified by place of birth of subject or father of subject, has again one of the 
highest scores of "implicative drinking" (Haberman and Scheinberg, 1967). This was an 
index derived from affirmative answers to a question covering the presence of alcohol- 
related problems (health, job, money, family), quantity of drinking (too much drinking), 
and personal reasons for drinking (for pains, to sleep, for energy, to relax). 



152 



Haberman's (1970) data, as was the case with that of Alcocer's and others 
previously described, confirms the differences between the sexes in patterns of drinking 
and alcohol problems among Hispanics. All the problem drinkers in the New York City 
sample of Puerto Ricans are males. While the proportion of abstainers among Puerto 
Rican women is 7^^%, among Puerto Rican men it is 16%. Thus, the female/male ratio 
of reported non-drinkers among Puerto Ricans is 'f.Sil, much higher than in any other 
ethnic group in the study. Data from the Health and Nutrition Examination Study 
(HANES) analyzed by Hartsock et al. (1979) show a rate of abstention for "Spanish 
women" (no definitions for this and other ethnic classifications are given) which is 2.5 
times higher than that for "Spanish" men (72% versus 29%), while "Mexican" women 
have a rate 1.8 times higher than "Mexican" men. Rates for heavier drinking (1 or 
more oz. ethanol per day) are equal for both Spanish and Mexican women, 2%. However, 
Spanish men have a rate of ^0% while for Mexican men the proportion is 23%. This 
is slightly higher than the proportion for "other" men which is 17%. 

Further confirmation of these sex differences in regard to drinking practices can 
be found in Maril and Zavaleta's (1979) report on drinking patterns of low income 
Mexican-American women. A total of 785 women, representing 11.5% of all low income 
Mexican-American women in the city of Brownsville Texas, were sampled. 
Approximately 86% of the women are abstainers (no alcohol consumption during the 
previous year). The preferred beverage for the women who drink (N=108) is beer. Of 
these, 59% report drinking 2 beers or less occasionally, 9% report drinking 3 or 'f beers, 
and 32% report drinking 6 or more beers. Women drinkers are more likely to be young 
and middle aged, married, and educated up to junior-high or high-school. 

A study by Hoick et al. (198'f) of alcohol use along the U.S.-Mexico border 
nrovides further insights on drinking by Mexican-American women by dividing this group 
among those who were born in Mexico and those who were born in the U.S A total 
of 2135 women 15-'t't years of age were interviewed; 1233 indentified themselves as 
Mexican-Americans, 799 as Anglo and 10^ as Blacks or from another ethnic group. In 
accordance with previous results, Mexican-American women have higher rates of 
abstention than Anglo women (1^7% versus 28%) but lower rates of heavy drinking (2% 
versus 6%). Among Mexican-American women unemployment, higher education and 

Erevious marriage are all associated with less abstention and more drinking. Women 
orn in Mexico have higher rates of abstention than Chicanas {l^7% versus 28%) 
independent of age, marital and employment status and years of education. 

A comparison of drinking practices and problems among different ethnic groups 
in the U.S. is reported by Jessor et al. (1968). The community studied is located in 
southwestern Colorado and for a community survey of this population the authors 
interviewed a random sample, stratified by sex and ethnicity, of 93 Anglos, 60 Hispanics, 
and 68 Indians. A comparison of mean scores on measures of frequency of intoxication, 
and drinking problems shows that Hispanics drink twice as much as the Anglos, but 
neither have a higher frequency of drunkenness nor a higher rate of drinking problems. 
The Indians drink seven times as much alcohol as the Anglos and three times as much 
as the Hispanics. Their rate of intoxication is seven times higher than that for the 
other two groups and they have six times as many alcohol related problems. 

Results for rate of deviance and alcohol use show Hispanics in the intermediate 
position between Anglos and Indians. Thus, while 9% of the Hispanics are described 
as "usually heavy" drinkers, only 2% of the Anglos are so characterized, against 26% 
of the Indians. Approximately 50% of the Indians report 5 or more occurrences of 
drinking-related deviance (e.g., fights while drinking), while the rate among Hispanics 
is 15% and among Anglos l't%. "Drinking in the morning sometimes or often" is 



153 



reported by 33% of the Indians, 22% of the Hispanics and 9% of the Anglos. The 
proportion of those who report having being drunk three or more times "last year" is 
also high among Indians, 38%, intermediate among Hispanics, 15%, and lower among 
Anglos, 3%. When broken down by sex, males report higher rates of problems than 
females in all three ethnic groups. 

Norms and Attitudes toward Alcohol Use 

One explanation as to why Hispanic men have a high rate of heavy drinking and 
alcohol problems comes from survey data on norms and attitudes toward drinking among 
Hispanics. These data show that norms and attitudes governing the use of alcohol by 
Hispanic men are more liberal than those of Hispanic women or of Anglos of both 
sexes. Part of this evidence comes from a study by Johnson and Matre (1978) carried 
out in two areas of Houston Texas, one a predominantly Mexican-American neighborhood 
and the other an Anglo area. A total of 109 Mexican- Americans and 73 Anglos were 
selected from the population 18 years and older. Selection methods were not strictly 
random, which limits the generalizability of the findings. 

Results show that Mexican-American men and women prefer to drink with friends, 
while Anglos have preference for drinking with the family. Mexican-American men 
are more likely than Mexican-American women and Anglos to see a "few beers as a 
good way to unwind". A total of 37% of the Mexican-American women think that it is 
all right for a man to be drunk at home, but only 7% allowed that of a women. Among 
Mexican-American men the proportion allowing a woman to be drunk at home is 15%, 
while 53% permit the same behavior in men. Anglos, independently of sex, have much 
more restrictive views on drunkenness: ">% of the men and 15% of the women allow 
drunkenness by a woman, and 16% of the men and 23% of the women think it is all 
right for a man to be drunk at home. In general agreement with their drinking behavior 
'i'i% of the Mexican-American men think it is all right for a person to be drunk at a 
party. The proportion of Mexican-American women, Anglo men, and Anglo women 
approving such behavior was muc|i smaller: 25%, 16% and 12%, respectively. 

Paine (1977) presents evidence that corroborates Johnson and Matre's findings. 
In fact they seem to have analyzed data from the same survey although by reading 
their papers this is not readily apparent. Paine's sample also comes from a Mexican- 
American working class neighborhood in Houston, Texas. He had 138 respondents, 32 
men and 106 women, and this sex disparity may have been a result of non-random 
selection of respondents. Drinking is very much a man's activity among these individuals. 
A total of 72% of the men surveyed are drinkers, against only 16% of the women. 
Men are allowed to ingest larger amounts of alcohol more frequently. ^^9% of the men 
and 38% of the women agree that it is all right for a man to get drunk at his house. 
The proportion of respondents accepting the same behavior in a woman was much lower: 
15% of the men and 6% of the women. In reference to alcohol use in general, 25% of 
the sample agreed that "a few drinks help a person to get through the day", and 29% 
thought was "all right to get drunk at a party". Finally, ^^9% of the drinkers (N='fO), 
and 29% of the nondrinkers (N=98) thought that "it is good to take a drink when you 
are feeling tense". 

Alcocer's (1979) study of drinking in East Los Angeles, Fresno, and San Jose also 
has data on drinking norms and attitudes among Hispanics. A substantial proportion of 
his respondents allow large amounts of drinking in some specific social situations: 30% 
condone being "high at a party", 39% accept being drunk with a friend at a bar, and 
19% approve being drunk during recreational activities. There is practically no support 
for drinking at work and before driving. There is support for mild drinking (1 or 2 



154 



drinks) when visiting friends (62% agree), during recreational activities (60% agree), by 
someone at honne (31% agree), when visiting parents ('fO% agree), and for a couple 
having dinner (7^% agree). When this data is broken down by sex, men consistently 
show more liberal attitudes than women. This pattern holds for all three communities 
in the study, although there were some differences among regions. Thus, respondents' 
liberality with regard to drinking was highest in Fresno and lowest in East Los Angeles. 
These regional differences were consistently found for all questions regarding drinking 
norms and attitudes. 

Drinking and Alcohol Problems Among Hispanics in the San Francisco Bay Area 

Between 1977 and 1980 a series of representative samples of residents of three 
counties of the San Francisco Bay Area were interviewed as part of a project to 
evaluate an alcohol prevention campaign (Wallack and Barrows, 1981). The prevention 
interventions and the evaluation study were funded by the state of California. A 
special component whose aim was to develop strategies to prevent alcohol problems 
among Hispanics was part of the overall project, and was funded by the National Institue 
on Abuse and Alcoholism through a grant to the California Commission on Alcoholism 
for the Spanish-Speaking, Inc. In the course of the evaluation of this Hispanic component 
it was realized that a combination of the collected samples would yield a total of 63^* 
Hispanics respondents. This number was larger than that in other studies and would 
allow for more detailed analysis of drinking patterns and alcohol problems among this 
ethnic group than in any previous study. A series of analyses were then undertaken in 
an attempt to better understand the ways in which alcohol is used by Hispanics. For 
detailed results of these analyses see Caetano (198^^3, 1984b, 198'fc). 

The samples were all collected with the same methodology. In each study area 
a sample of housing units was selected by area probability methods, and one respondent 
between 18 and 59 years of age was randomly selected from each household for 
interviewing. The institutional population was not covered. Also, because the subjects 
were interviewed in different surveys, the sample cannot be regarded as representative 
of any one particular Hispanic population at one moment in time. The totpil number 
of persons interviewed is 't^lO. The 634 respondents who identified themselves as 
"Latino, Mexican, Mexican-American, Chicano, or Hispanic Heritage" were all grouped 
under the rubric "Hispanic" and analyzed together. The sex and age distribution of 
the sample and the proportion of respondents who are high school graduates and 
unemployed do not differ from that of the Hispanic population of the Standard 
Metropolitan Statistical Areas (SMSA) of San Francisco, Oakland and Stockton (Bureau 
of the Census, 1982; 1983a; 1983b). However, the combined sample shows some variation 
in sociodemographic characteristics from the Hispanic population in the SMSAs. The 
combined sample has fewer people in the "$20,000 and more" income category (22% 
versus 42%) than the Hispanic population of the SMSAs under comparison (Bureau of 
the Census, 1983a). The combined sample also has fewer people who are single (19% 
versus 33%) (Bureau of the Census, 1983a). Finally, there are more people of Mexican 
origin among respondents than in the Hispanic population of the SMSAs (80% versus 
60%) (Bureau of the Census, 1982). This is probably because the Hispanic population 
of San Francisco, which is predominantly from Central America, is included in one of 
the SMSAs although it was not sampled for the survey. 

The results of this series of analyses confirmed previous findings in the literature, 
besides providing new insights on patterns of alcohol use among Hispanics. Abstention 
is high among females (32%) and low among males (14%). In contrast, a quarter of 



155 



the males are frequent heavier drinkers6, but only 3% of the females are so. Among 
males drinking is positively associated with being young and separated or divorced. 
Among females drinking is positively associated with being young, being more educated 
and being single, separated or divor*" The best predictors of alcohol consumption 

according to a regression analysis are being a male, having liberal attitudes toward 
alcohol consumption and being more educated. Comparison of Hispanics with Whites 
and Blacks in the same sample throws further light on these findings. Table 6 shows 
that Hispanic males have a rate of abstention lower than Blacks but comparable to 
Whites. Hispanic males also have more frequent heavier drinkers than the other two 
ethnic groups. Hispanic females, as in other surveys, have more abstainers and fewer 
frequent heavier drinkers than females in the other groups. Results in Table 7 provide 
deeper understanding for the differences across groups. The most important finding in 
this table in the difference across groups in the patterning of frequent heavy drinking. 
Among Whites, the rate for frequent heavy drinking drops by half from the 19-29 to the 
30-39 age group, remaining stable after that. Among Blacks frequent heavier drinking 
follows an inverse pattern, it almost doubles from the 19-29 to the 30-39 age group, 
declining in older groups. Among Hispanics, there is a third pattern. The rates drop 
continuously with age so that the percentage of frequent heavier drinkers among younger 
men is almost four times higher than among those 50-59 years of age. 

Hispanic men also have a higher rate of alcohol problems than men in the other 
two groups. Since alcohol consumption is closely associated with rate of problems, the 
distribution of problems by age follows very closely the pattern of frequent heavier 
drinking depicted in Table 7. The prevalence of four or more problems among men in 
each of the ethnic groups under comparison is shown in Figure 1. The patterning 
unveiled offers quite a contrast across groups. Hispanics have more problems than 
Blacks and Whites throughout. Among Whites the patterning of problems by age is in 
accordance to that traditionally described in surveys of the U.S. general population. 
It fits well with the notion that drinking problems in the general population are 
concentrated among young males and are part of a youthful life style (Cahalan and 
Room, 197^*). Among Blacks and Hispanics, however, drinking problems cannot be seen 
as a characteristic of the young for they are more often present among more mature 
adults than among men in their twenties. The important significance of this finding 
for the identification of target groups for prevention will be discussed below. 

The prevalence of specific problems by sex among Hispanics and Whites is depicted 
in Table 8. Men have far more problems than women. Among Hispanic men the most 
prevalent problem is the harmful effect of drinking on health. About a tenth of these 
men also report harmful effects of drinking on financial position, home life and 
friendships and social life. As a comparison, the prevalence of these same problems 
among White men is two thirds of that for Hispanics. The rate for each of these 
problems among Hispanic women is low and not very different from that among White 



6. Quantity-frequency categories were defined as follows: a) frequent heavier drinkers: 
drinks five or more drinks at a sitting, once a week or more often; b) frequent high 
maximum drinkers: drinks once a week or more often and drinks five or more drinks at 
a sitting at least once a year; c) frequent low maximum: drinks once a week or more 
often but never drinks as many as five drinks at a sitting; d) infrequent: drinks less 
than once a week but at least once a month, may or may not drink five drinks at a 
sitting; e) occasional: drinks less often than once a month; f) abstainer: has not drunk 
alcohol beverages in the last six months. One drink means 1 oz of spirits, a 4 oz glass 
of table wine or a 12 oz can of beer, each of which contains approximately 9 g of 
absolute alcohol. 



156 



women. Among Hispanics the best predictors of problems as determined by regression 
analysis are the number of drinks consumed per month, the frequency of drunkenness, 
being a male and being unemployed (Table 9). Together these four variables are 
responsible for 26% of the variance in problems data in the sample. 

Since frequency of drunkenness is an important predictor of problems, and since 
drinking by Hispanics in the U.S. has been characterized as "fiesta drinking", i. e., 
drinking to intoxication in special occasions, a detailed analysis of self-reported 
intoxication in the sample was undertaken (Caetano, 198^c). Results show that the 
frequency of getting intoxicated at least once a month is 20% among Hispanic men 
and 15% among Anglo men. Data breakdown by age shows that 22% of Hispanic men 
in the 18-29 and in the 30-39 age groups get drunk at least once a month. This 
frequency declines in older age groups, being 17% for the age group ttO-^9 and 11% for 
the age group 50-59. When compared with findings for Whites in the same sample, 
Hispanics have higher levels of intoxication for every age group with exception of the 
19-29 group where 26% of the Anglo men get drunk at least once a month. Intoxication 
is less prevalent among women than among men. About 6% of Hispanic women and 5% 
of Anglo women report intoxication at least once a month. Rates of drunkenness once 
a week or more often by age show that Hispanic women have higer rates of intoxication 
than Anglo women in the 30-39 (7% versus 'f%) and ^0-^9 age groups (6% versus 0%). 
Anglo women have higher rates in the 18-29 age group (10% versus 6%), while rates in 
the 50- "9 age group are similar (1% and 0%). 

Because about 80% of the Hispanics in the California sample being analyzed are 
of Mexican origin, a comparison with patterns of drunkenness among a random sample 
of residents from rural and urban areas near Mexico city is enlightening. Results for 
the Mexican data were published by Calderon et al. (1981) and Caetano (1984d). Among 
the men in Mexico, 29% reported intoxication once a month or more often, a rate 
higher than that found among Hispanic men in California (20%). Further, among Mexican 
men 22% of regular drinkers (drink once a week or more often), 35% of intermediate 
drinkers (drink one to three times a month) and 51% of the occasional drinkers (drink 
less than once a month) report drunkenness with the same frequency with which they 
drink. Using the same classification of drinkers, results for Hispanic men in California 
are as follows: 21% of regular drinkers, ^% of intermediate drinkers and 7% of the 
occcisional drinkers report drinking and becoming intoxicated with the same frequency. 
Thus, while the rates for regular drinkers are similar in Mexico and California, 
intermediate and occasional drinkers in Mexico seem to get drunk much more frequently 
than their counterparts in California. Overall, 50% of male drinkers in the Mexican 
sample get drunk everytime they drink, while among Hispanics in California only 17% 
do so. 

This high frequency of drunkenness together with a comparatively low frequency 
of drinking suggests that drinking and drunkenness in Mexico are more closely associated 
than in the U.S. This is in accordance with "fiesta drinking", and even though occasional 
and infrequent drinkers in California do not get drunk as oftenly as in Mexico, it also 
suggests that the increased frequency of drunkenness among Hispanic men in California 
may be a pattern of drinking brought from Mexico which has not undergone total 
acculturation. Finally, the increased frequency of drunkenness among Hispanic men in 
California is also of importance for prevention During intoxication one has a higher 
chance of experiencing a number of alcohol problems. It is easier to fall down and 
hurt oneself, it is easier to get into bar-room fights, and if one drinks and drives, it 
is easier to be involved in a car accident. Thus, minimizing the frequency of this 
drinking behavior may help reduce alcohol problems among the Hispanic population. 



157 



Attitudes toward alcohol use are also an important predictor of drinking behavior. 
The analysis of drinking by Hispanics in the San Francisco Bay Area looked at differences 
in attitudes by sex and age as well across Anglos, Blacks and Hispanics (Caetano, 
198^a). Within the Hispanic group liberal attitudes toward alcohol use are associated 
with being a male, being young, less educated, single and separated or divorced. When 
compared to Anglos and Blacks, Hispanics had more liberal attitudes than the other 
two groups (Table 10). This is especially true for those items which support drunkenness 
as an emotional outlet or as a vehicle for having fun, as well as for items that tap 
the power of alcohol as a social lubricant. These results confirm previous findings in 
the literature (Johnson and Matre, 1978; Paine, 1977; Alcocer. 1979) discussed earlier 
on this review, and they also map well onto Hispanics' higher rate of alcohol use and 
higher frequency of drunkenness. They also provide important directions for prevention, 
underlining once more the importance of focusing interventions in changing specific 
perceptions of alcohol use in the Hispanic community — alcohol as a social lubricant 
— as well as specific drinking behaviors — drunkenness. 

Finally, Hispanics' knowledge about drinking and its effects was also analyzed 
using the items in Table 11 (Caetano, 1983). The truth or falsity (T or F' of the 
statements are indicated in parenthesis in the Table. It is immediately apparent that 
the majority of respondents know the effects of alcohol use, independent of sex. The 
items on amount of drinking and speed of intake (no. 3) and that on drinking and weight 
(no. i^) have a lower proportion of correct answers. This is interesting because ignorance 
about the relationships expressed in these items could lead to inadvertent intoxication, 
a drinking behavior which is shown by other results in the Bay Area study to be high 
among Hispanics. Examining the results across ethnicity shows that both Whites and 
Blacks also give a lower proportion of correct answers to these two items. Hispanics' 
answers are similar to those of Blacks and lower than those of Whites. The items on 
how Californians drink also have a lower proportion of correct answers, a pattern that 
cuts across ethnic groups. Among Hispanics, analysis by age did not show any significant 
patterns. It is not possible to compare these results with previous findings in the 
literature since knowledge as represented by the items depicted in Table 11 has not 
been cissessed before. It is possible however to see that the results are relevant for 
prevention. Hispanics seem to have a good knowledge of the basic effects of alcohol 
such as that it is a stimulant, that it can be an addictive drug, that use may bring 
serious damage to health, that it is a drug commonly associated with drugs and violent 
acts. Therefore, the use of preventive campciigns to impart this type of knowledge 
hoping that increase in knowledge will minimize alcohol use and problems is bound to 
fail. Other strategies different from those which rely exclusive in alcohol education 
need to be developed for alcohol prevention among Hispanics and some suggestions in 
this area will be given below. 

Community perception of alcohol problems as legitimate areas for official 
intervention are also of importance for prevention. The study of Hispanics in the Bay 
Area asked respondents about their ranking in degrees of importance for a number of 
alcohol-related problems. These data were analyzed by Randolph (198'f) and Table 12 
reproduces some of her results. In general, Hispanics are more concerned than the 
other two groups about almost all the problems in the Table, and Blacks are more 
concerned than Whites. Concern seems to be especially high for drunk driving, family 
troubles, teenage drinking, littering and public drinking. This latter problem, which is 
known to occur much more frequently in poor, inner city, ethnic neighborhoods is of 
more concern for Blacks and Hispanics than for Whites. Littering and public drinking 
have also been associated with the disproportionate number of liquor outlets in ethnic 
neighborhoods, and both Hispanics and Blacks are more concerned than Whites about 
this particular problem. In California, Engmann (1976) found that 60% of the zip codes 



158 



with highest concentration of retail alcoholic beverage licenses statewide were areas 
with Hispanic population above the statewide average. Other analyses have shown that 
both Black and Hispanic neighborhoods in Los Angeles (Burns, 1983) and Milwaukee 
(Farrel et al., 198^) have a higher concentration of alcohol outlets than residentied 
areas with a predominantly White population. The relationship between the increased 
presence of these outlets and alcohol-related problems is supported by data from 
Milwaukee where 80% of alcohol-related criminal activities in 1981 could be related 
to ten taverns in three districts of that city. 

Ethno^aphic Research 

The focus of this review is on the epidemiological literature on alcohol use 
among Hispanics. However, the ethnographic research cannot be forgotten due to its 
important contribution to the understanding of drinking by members of this ethnic group. 
There have been a number of reviews of the contribution of anthropologists to the 
alcohol field in general (see Heath 1975, Bennett 198'f; Room, 198't). The four papers 
briefly reviewed below cover each one of the major national groups of Hispanics and are 
a good example of this contribution. They have a richness of description that 
complements well the epidemiological data. Their findings show the heterogeneity of 
drinking patterns of the various Hispanic groups but also underline the commonalities 
among these groups. A good example of the latter is the sharp contrast between the 
drinking practices of Hispanic men and women which is an epidemiologiccd finding 
confirmed in this ethnographic research. 

Gilbert (198^^) describes variations in drinking practices according to social context 
among Mexican-Americans in California. In family celebrations such as weddings and 
birthdays the emphasis is on conviviality. Drinking goes together with eating, and the 
presence of women and children is a powerful restraining factor on how much alcohol 
is consumed. When someone exceeds acceptable limits of drinking, friends and famly 
members immediately intervene to limit or stop alcohol consumption by that person. 
In contrast with this familiar scene there is the drinking that occurs outside family 
boundaries, in cantinas. These are male-oriented establishments and the rules that 
govern drinking behavior in this context are much more lax. There is an emphasis on 
heavy drinking and sexual overtures to the women are accepted. A third drinking 
setting described by Gilbert is that of the nightclub. Drinking is heavier among men 
than among women. Attitudes governing drinking behavior vary from one club to the 
other and are class related. 

Gilbert's description of the sharp contrasts between drinking practices by men 
and women map well onto the epidemiological findings. Among men, drinking is an 
important vehicle for social interaction in same-sex situations as well as in social 
situations that involve interaction with women. Men drink together as respite from 
work. If one fulfill one's obrigations at work and as a family provider, drinking is a 
right. Among women "respite drinking" and drinking in same sex situations are not 
common patterns. Women restrict their drinking to family reunions, where drinking is 
limited by restrictive norms. Acculturation and entrance into the work force may, 
however, be changing these practices and blurring the contrasting drinking practices 
between the two sexes. 

Drinking among Mexican-Americans in South Texas is also a men's activity. 
Alcohol use among women is constrained by the concepts of "virtue" and "respect" 
(Trotter, 198't). Role differentiations between the sexes lead to different preferences 
for drinking settings and different choices of drinking companions. There is a tendency 
for males to drink with other males and outside the home, and for females to drink 



159 



at home and in those public places where drinking occurs but where the emphcisis is 
in other kinds of activities, like dancing. Alcohol use among these Mexican-Americans 
also varies according to lifestyles associated with working conditions. Alcohol use is 
widespread in migrant-worker camps of the Eastern Seaboard where the population is 
composed mainly of single males. Migrant workers laboring in Midwestern farms travel 
with their family to camps where drinking is not allowed. Among the working poor 
with steady employment, drinking is patterned by age, with the young having more 
liberal attitudes than the old. Among the middle class and the elite, women have 
relatively more freedom to drink. 

Gordon (198'f) compares alcohol use among Dominicans, Guatemalans and Puerto 
Ricans in New England and his findings underline the variation in drinking practices 
across different groups of Hispanics. Dominicans' drinking has diminished as a result 
of immigration to the U.S. and subsequent upward social mobility. Social drinking still 
is an accepted activity but there is also a strong emphasis on self-control. Drunkenness 
and heavy drinking during weekends are proscribed. Guatemalans drink more heavily 
than Dominicans. Guatemalan men arrive in the U.S. alone, and this lack of family 
ties facilitates excessive use of alcohol consumption. Drinking occurs mainly outside 
the home and with other men, leading frequently to drunkenness and prolonged binges 
that last from Thursday to Sunday. Puerto Ricans are more acculturated to the U.S. 
than the other two groups and have incorporated U.S. drinking practices along with 
more traditioneil ones. They drink lightly during weekdays and heavily during weekends. 
Drug use is more prevalent among them than among other Hispanic groups. 

Cuban-Americans residing in Miami have been studied by Page et al. (198'f). 
Unfortunately, the men interviewed in this study were all polydrug users and, as the 
authors acknowledge, hardly representative of men in the general Cuban-American group. 
Traditionally, there are norms that strongly proscribe drunkenness both among men and 
women. There is an emphasis on alcohol use without loss of self-control and men 
consistently deny intoxication to comply with this norm. Cuban-American women drink 
little, and younger women drink more frequently than older women. 

Conclusions 

This has been a review of the epidemiological literature on alcohol use among 
U.S. Hispanics. This body of papers has some faults, and many of its findings need to 
be interpreted with caution. The knowledge obtained from studies with indirect indicators 
of alcohol problems is very limited. This research says nothing about abstinence or 
light drinking and gives little information on the long term results of heavy alcohol 
intake. There is some indication that Hispanics are overrepresented among those dying 
of alcohol-related causes. However, this evidence is limited to a few cities or counties 
located mainly in the Southwest. Little is known about the status of this problem in 
the rest of the country. There are also limitations in those studies based on treatment 
statistics or alcohol-related arrests. The former provides scant information, which is 
usually biased by the many factors that operate in determining who receive treatment 
and who doesn't. 

Statistics on public drunkenness and drunk driving offer a consistent picture: 
Hispanics are overrepresented among those in police custody for alcohol-related arrests. 
But is it really that because Hispanics drink more than other ethnic groups they have 
more problems with the police and a high rate of arrests, or this is just a result of 
increased police surveillance of minorities? The evidence at hand is controversial and 
as of now cannot provide a satisfactory answer to this question. However, the problem 
is increasingly important. Drunk driving is now under considerable attention from the 
public and authorities. So far the response to the problem has been characterized by 



160 



an amplification of police powers, which has resulted in the use of random road checks, 
stiffer penalties and mandatory treatment for first offenders. The long term results 
of these measures are yet to be evaluated. It seems narrow minded and over-optimistic 
to think that police enforcement by itself will solve a problem with roots in the norms 
that regulate alcohol use among minority groups as well as in the secondary place that 
these groups occupy in American society. Independent of whether minority groups have 
indeed a disproportionate number of drunk drivers, if police efforts to curb this problem 
result in the aprehension of a large number of minority persons these measures may 
be seen by minority groups as yet another instance of discrimination. 

The results of surveys of alcohol use also have limited value with regards to 
Hispanics. Most of these projects were not developed to study this ethnic group, and 
the number of respondents identified as Hispanics is a small percentage of the total 
sample. Therefore, most descriptions of patterns of alcohol use by members of this 
group are but underdeveloped branches of larger analyses directed to other groups or 
to the general population as a whole. Alcohol studies with Hispanics have not provided 
insights on the associations among alcohol consumption, drinking problems eind 
sociodemographic variables, on the evolution of drinking problems over time, on the 
associations among different problems, and on problem predictors, to mention but a 
few areas. Exceptions are the studies by Aicocer and the analysis of drinking among 
Hispanics in the San Francisco Bay Area discussed in this report. But these two studies 
also have limitations that affect the generalizability of their results. 

Shortcomings aside, community studies of alcohol use have provided a tentative 
picture of Hispanic drinking in the U.S. that deserves some attention. Hispanics seem 
to be concentrated at the extremes of the drinking scale distribution, that is, in the 
heavy drinking and the light drinking/abstaining categories. They have a higher rate 
of alcohol problems than the U.S. general population. The norms and attitudes that 
govern alcohol use in the Hispanic community are liberal for men and restrictive for 
women and more so than the norms of the general population of the U.S. As a result, 
there are sharp contrasts between male and female drinking practices. The heavy 
drinking category is mostly populated by men, while the women are mostly abstainers. 
Consequently, most problems are reported by men and often, in what may well be a 
tribute to the tension between an abstaining wife and a heavy drinking husband, affect 
family relations or marriage. Drunkenness seems to be an accepted drinking pattern, 
more so than among Whites and Blacks, and as such may contribute to the high 
prevalence of alcohol problems among Hispanics. The constrasting drinking patterns of 
men and women and the variation in drinking practices across different national groups 
or different subgroups of Hispanics is underlined in ethnographic research. 

Recommendations for Research 

The criticisms developed here underscore the limited nature of the information 
on alcohol use by Hispanics It would seem that before moving ahead into new areas 
of inquiry some of the unsettled issues raised by this literature should be dealt with in 
an adequate manner. One area to be addressed is that of indirect indicators of alcohol 
problems. There is urgent need for future research in alcohol-related mortality among 
Hispanics. At present death certificates do not have a place for coding ethnicity and 
therefore mortality information cannot be tabulated by this characteristic. This code 
should be created so that these data can be made available at national and state level. 
In the meantime, the coding for country of birth in the death certificate can be used 
to provide information on those Hispanics who were born outside the country. 
Alternatively, it is possible to use Spanish surname as an indicator of ethnicity. This 
procedure has well known limitations such as inclusion of non-Hispanic individuals who 



161 



for reason of marriage or otherwise have Spanish-surnames, and exclusion of Hispanics 
who do not have traditional Spanish surnames. However, such studies could provide a 
base for assessment of alcohol-related mortality among Hispanics while the ethnic code 
in the death certificate does not become available. 

It is also important to develop studies to evaluate both police handling of alcohol- 
related arrests and long term effectivenes of increased police enforcement of drunk 
driving among Hispanics. These investigations should be more than mere analysis of 
changes in official statistics with time. It is important that these studies provide 
details of police enforcement practices as well as a description of arrestees in terms 
of usual drinking habits and sociodemographic characteristics. Description of arrest in 
term of place, time, reasons for and behavior that prompted arrest are also very 
important if this alcohol-related problem is to be better understood and if police bias is 
to be ascertained. P rhaps the most profitable methodological approach for such studies 
is a mixture of ethnographic-like descriptions of police enforcement and quantitative 
analyses. 

Another area in need of further development is that of survey research. One of 
the requisites for future efforts in this territory is the study of larger and representative 
samples of Hispanic individuals and the use of more sophisticated techniques of data 
analysis. At the moment of this writing a national study of alcohol use and drinking 
problems among Hispanics which will satisfy these and other requirements is being 
conducted by the Alcohol Research Group with support from the National Institute of 
Alcohol Abuse and Alcoholism. This study will interview approximately 1,500 Hispanics 
nationwide, in accordance to a probability sample design of this ethnic group in the 
U.S Data is being collected by trained personnel in face to face interviews. The 
questionnaire asks detailed information in the areas of demographic characteristic, 
drinking patterns, drinking in the context of family life, work setting, and social group 
affiliations, attitudes and norms on drinking and responses to drinking problems, drinking 
problems, treatment experiences, life experiences, depression, migration and 
acculturation. The study will also interview a representative sample of Blacks and it 
is also being conducted together with a nationwide probability sample of the adult U.S. 
population. Because these three samples are being interviewed with the same 
questionnaire, findings can be compared across populations which will enrich the 
descriptions and provide a deeper understanding of characteristics of alcohol use and 
its relationship with problems in each populational group. 

Also at the national level there are data on Hispanics collected by the Hispanic 
Health and Nutritional Examination Survey (Hispanic HANES). This survey will yield 
rich information about Hispanics' health status, covering such areas as alcohol 
consumption and smoking, depression, disabilities, dietary habits, nutrition status, blood 
pressure, serum cholesterol, height, weight, and other physiological and body 
measurements. The extent of heart disease, diabetes, hypertension, liver disease and 
other chronic conditions will also be measured together with health care utilization. 
The questions on alcohol use cover the consumption of beer, wine and liquor in a 
reference-period of li weeks, or if the respondent did not drink in this period in the 'f 
weeks previous to the last drinking occasion. There are also questions on reasons for 
drinking, abstaining and heavy drinking. Given the data coverage in this study, one of 
its many strengths is the possibility of studying the relationship between alcohol 
consumption and health status and physical ailments. There is very little data on this 
area for Hispanics and this Hispanic HANES is therefore a welcome development 

Surveys concentrated in areas with large and more homogenious Hispanic 
populations than that interviewed in a national study are also important to conduct. 
Geographically limited surveys have the advantage of providing more accurate 



162 



^ 



information on regional or national differences in drinking habits across Hispanic groups 
which are important for designing treatment and prevention strategies. The total costs 
involved in conducting such a series of surveys would undoubtly be higher but the 
information they provide will be more useful in planning adequate responses to alcohol 
problems at the level of local communities. Since epidemiological research on alcohol 
problems is not conducted with the sole purpose of advancing our understanding of how 
alcohol problems develop but aims also at contributing to the public health effort of 
preventing such problems, this latter approach should receive detailed consideration 
Doth from researchers and planners. 

Responding to Alcohol-related Problems among Hispanics 

Before attempting to make suggestions as to what types and how alcohol problems 
among Hispanics should be prevented, a brief review of the relationship between the 
epidemiology of alcohol problems in the general population and the development of 
prevention strategies is in order. Findings from alcohol research in the general population 
have repeatedly shown a picture of the distribution of alcohol problems in the community 
which contradicts the traditional disease concept as put forward by 3ellinek (195z, 
1960), and the notion that treatment and prevention policies should be developed under 
this paradigm. While the disease concept proposes that alcoholism is an entity with a 
pathognomonic symptom - loss of control over the amount of alcohol ingested - eis well 
as predictable phases and evolution, epidemiological findings indicate that alcohol 
problems in the general population are much more disaggregated than would be expected 
if they were all symptoms of an underlying condition. Studies have shown that having 
a particular drinking problem is only a modest predictor of having any other type of 
drinking problem, and that having a drinking problem at a certain point in time is only 
a modest predictor of having the same problem at another time (Room, 1977). Drinkers 
also seem to get in and out of problems spontaneously (Roizen et aU, 1978; Clark, 
1976). Loss of control is not an irreversible phenomenon that marks the beginning of 
some new drinking pattern qualitatively different from the previous one (Clark, 1976). 

Results also indicate that the distribution of alcohol consumption in the general 
population is not bimodal. In other words, drinkers distribute themselves along a 
continuum, with no "bump" at the upper end of the distribution that can be attributed 
to alcoholics. Further, sociodemographic variables offer a potential source of explanation 
for differences in drinking patterns and alcohol problems. Characteristics such as sex, 
age, income, etc., show statistically significant associations with drinking and contradict 
the notion that problem drinking is a condition due only to an etiological factor carried 
by the individual. In general, the drinking histories of problem drinkers in the general 
population do not seem to follow a predictable pattern like that described by AA 
members and Oellinek (1946) and which characterizes problem drinkers who seek 
treatment. In spite of all the alcohol problems present in the community, the proportion 
of people with drinking patterns similar to those in the clinical population is only about 
1% (Room, 1968), a finding which suggests that prevention efforts developed under the 
disease concept and which aim at locating the pre-alcoholic or hidden alcoholic in the 
community are inefficient. 

These results come from studies conducted in a majority of cases with non- 
Hispanic populations, with Hispanics forming only a small fraction of the subjects. 
However, while the patterns of association between problems and sociodemographic 
variables, the prevalence of different types of problems and the norms and attitudes 
that govern alcohol use are specific to the Hispanic group, the disaggregative nature 
and the evolution of alcohol problems are not. These two attributes of alcohol problems 
are shared by non-clinical populations and, therefore, it is feasible to develop general 



163 



approaches to prevention which will be applicable across ethnicity to all groups in the 
community. Taking these results into consideration it would seem that the response 
to alcohol problems among Hispanics as well as that directed to the population as a 
whole should be comprehensive, with a clear priority for prevention as well as treatment. 
The population which will be benefited by treatment services is but a small fraction of 
all of those with alcohol problems, and treatment is relatively expensive and often has 
modest results. In organizing treatment for alcoholics it may be well to keep in mind 
recent findings from a randomized clinical trial which suggest that firm advice from 
the appropriate professionals is worth as much as the more sophisticated inpatient or 
outpatient treatment offered in many specialized units (Edwards et al., 1977). 

The thrust of the response to alcohol problems should be in the form of sustained 
and comprehensive prevention interventions. Two basic strategies can be followed in 
organizing preventive measures: a) reducing the demand for alcohol in the population; 
b) reducing alcohol availability in the community. In the first case the aim is to 
change people's drinking habits through education, persuasion and community 
organization. Currently available evidence suggests that educational efforts alone will 
not be successful in preventing alcohol problems or encouraging moderation in drinking 
habits (Wallack, 1980; Blane and Hewitt, 1977). In trying to change a deeply rooted 
behavior such as alcohol use, the mere provision of new information is of limited value 
(WHO, 1980). Educational campaigns should be developed and implemented in 
combination with other preventive efforts. 

One recent prevention effort whose failure to produce significant changes in 
drinking habits underlines the importance of these points was the California Prevention 
Demonstration Project (see Wallack and Barrows, 1981 and Caetano, 1982 for details). 
This project had an important component aimed at preventing excessive alcohol use 
among Hispanics supported by the National Institute of Alcohol Abuse and Alcoholism 
through a grant to the California Comission on Alcoholism for the Spanish-speaking, 
Inc. The campaign used state-of-the-art methodology in its evaluation component. This 
was a quasi-experimental design involving three communities, two experimental and one 
control, and three stages of data collection through community surveys, before, during 
and after the interventions. The campaign's message of moderation was disseminated 
through the mass media, and used specifically made site spots on Spanish language 
televison, radio and outdoor billboards. In one study there was also a community 
intervention component, which consisted of community meetings organized by campaign 
staff to further disseminate the message of moderation and assure community 
participation in the preventive effort. Other vehicles used to propagate the campaign 
message were calendars, bumper-stickers, car stickers and a newsletter. Had this 
campaign relied on other preventive efforts besides public education, the results might 
have been different. As organized it constituted an isolated effort sustained for a 
limited amount of time and, with hindsight, with little chances of success. Also, the 
campaign relied little in survey research findings to focus on specific drinking behaviors 
and problems with high prevalence in the community. 

In attempting to reduce alcohol availability in the community, a number of 
measures have been suggested (Bruun et al., 1975; also Room, 198'fb for a review). 
One measure that has been suggested is some limitation on consumers, which in our 
societies means limiting the purchase of alcohol to those above a certain age limit. 
Another suggestion refers to placing some limitation on the frequency and type of 
outlets and hours of sale. This measure may be particularly relevant to the prevention 
of alcohol problems among Hispanics due to the apparent increased concentration of 
alcohol outlets in Hispanics neighborhoods and their association with an increased 
prevalence of problems. Some form of price control as well as control of advertising 
are other measures that have been suggested as effective in lowering alcohol 



164 



consumption. Some of these Interventions can be developed and implemented at the 
federal level, some other at state and local level. In the U.S, it is not possible for a 
local community to attempt to control consumption by increasing taxation or decreasing 
production of alcoholic beverages. These are measures that can only be implemented 
at federal or state level. At the local level it may be more feasible and appropriate to 
try to regulate the hours of sale or the number of alcohol outlets in the community by, 
for instance, using local zoning ordinances (Wittman, 1982). Finally, some problems 
may also be ameliorated by insulating behavior from consequences (Room, 1975). Thus, 
providing free taxi for those who leave bars intoxicated may minimize drunk driving 
accidents. Similarly, organizing "wet hotels" where people can drink in a protective 
environment may diminish accidents associated with being drunk in the streets (falls, 
fights, etc.) as well as public drunkenness arrests and police workload. 

Any set of preventive interventions needs to be developed with care if it is to 
be effective. First, it is necessary to obtain community input at all stages of planning 
^id implementation. In attempting to strengthen ties with the community, attention 
should be paid to those institutions and people who are not formally recognized as 
responding to alcohol problems but which do provide services in this area. These 
informal responses may be provided by the clergy through their leadership and counseling 
role, by emergency-room personnel, by general practitioners, and by various agencies 
and programs such as those dealing with, battered women, child abuse, etc. In a recent 
survey of services provided by community agencies in Contra Costa County, California, 
Weisner (1981) identified around 200 non-alcohol specific agencies which, in many 
different ways, provided services for people with alcohol problems or for their families. 

With respect to Hispanics, the Catholic church is an important institution whose 
f>articipation is necessary in alcohol prevention. Many Hispanic "fiestas" are linked to 
religious celebrations. While drinking is not an original part of the religious activities, 
it is built by popular tradition in the festivities that evolve around the holiday. Support 
from the church and at the local level from the the priest, who is seen as a respected 
community leader whose advice is sought for both religious and non-religious matters, 
are therefore important for prevention. Ethnic organizations also have input in Hispanic 
communities and can be of help in developing community acceptance for prevention. 
An instance where the activities of these groups could have been directed toward 
prevention within the Hispanic community is given by the recent alliance developed 
between Hispanic ethnic organizations and Adolph Coors Co. (Del Olmo, 198^^). Coors 
has been interested in increasing their share of the beer market among Hispanics, and 
an advertising campaign targeted for Hispanics has been developed in states with large 
Hispanic populations (Modern Brewery Age, 1980). The accord between Coors and six 
Hispanic organizations is part of this campaign. 7 Coors will hire more Latino workers 
and increase business transactions with Latino owned companies. However, after 1990 
all benefits to the Hispanic community will depend on how much Coors beer has been 
consumed by Hispanics in the meantime. Making it explicit, this means that Hispanic 
organizations involved in this plan have become partners of Coors in its attempt to 
increase alcohol consumption among Hispanics in the years ahead. A similar agreement 
has been reached between Coors and the Los Angeles chapter of the National Association 
for the Advancement of Colored People. 

Second, the interventions need to be both population and problem specific. That 
is, they should be tailored to the problem to be prevented and the "target" group for 



7. The organizations are: National Council of La Raza, National IMAGE Inc., American 
GI Forum, Hispanic Chamber of Commerce, National Puerto Rican Coalition and the 
Cuban National Planning Council. 



165 



whom they are intended. This specificity is necessary because of the disaggregation 
that characterizes the distribution of alcohol problems in the general population and 
because of the wide range of health and human behavior affected by these problems. 
Preventing drunk driving among young adults is different from attempting to minimize 
public drunkenness among derelict middleaged men or heavy drinking by pregnant women. 
Based on the results of the studies reviewed in this report, among Hispanics the most 
obvious candidates for concentrated attention are the males, especially those in middle 
ag^e. These men have a high rate of heavy drinking and drunkenness which are drinking 
behaviors closely associated with alcohol problems. Some attempt to minimize these 
behaviors is therefore in order. These men are also in an age group which is highly 
affected by cirrhosis, a serious medical problem which takes a heavy toll in premature 
mortality and which should be prevented. Further, default in their social roles as 
bread-winners and role-models for children because of heavy drinking is likely to affect 
not only their lives but the family and the community in many severe ways. They 
should, therefore, constitute prime targets for any prevention efforts directed at this 
ethnic group. Specific problems to be dealt with are those affecting health and family 
relations. The liberal views toward intoxication that seem to be present among Hispanics, 
as well as the importance given to alcohol as a social lubricant should also be taken 
into consideration in designing interventions. The association between drunkenness and 
the increcised risk of problems that such state brings needs to be underlined. 

Besides specificity of aims another important aspect of prevention interventions 
is cultured sensitivity. Epidemiological studies and ethnographic research alike are 
conducted not only to provide prevalence rates on different types of problems and 
patterns of drinking but also, and equally importantly, to provide a framework for 
better understanding the many ways in which alcohol use is interwoven in the culture of 
a particular ethnic group. The studies reviewed here show that drinking is a well 
accepted activity among Hispanics, one which provides recreation, accompanies 
festivities and the renewing of friendship and kinship bonds, and which is even seen as 
a right earned through the fulfillment of family and social obligations. Anglo culture 
in the U.S. has a tradition of preoccupation with the evils of alcohol that goes back to 
the 19th century and the temperance movement. In this culture alcohol was seen for 
many years as the major source of social and health problems: for many Americans 
today as in the past, nothing good could or should be said about it. This focus on the 
bad aspects of drinking culminated in 1919 with the passage of the 18th ammendment 
and prohibition. In 1933 prohibition was repealed and drinking became once again an 
acceptable social activity. Variations on this history of dealing with concern about 
alcohol are shared by the U.S., and other English-speaking and Northern European 
countries, but are not part of the recent history of alcohol in Latin American nations. 
Variations between Anglo and Hispanic norms and attitudes toward alcohol consumption 
may be related to these historical differences. Hispanics seem to have a more liberal 
view of alcohol use than Anglos as part of their cultural heritage. Thus, they may 
not necessarily see even heavy drinking as a bad thing which needs to be changed, 
especially if such a heavy drinking does not interfere with family and social obrigations. 
Given these differences in perceptions about alcohol use, approaches to prevention that 
may be acceptable and successful among Anglos may not be so among Hispanics. Public 
health professionals and all of those working in the alcohol field need to take these 
differences into consideration when planning prevention interventions directed at U.S. 
Hispanics. 



166 



Table 1: Arrests for Alcohol-related Offenses by 

Hispanic origin; 1981. 



18 years of age and older 

Hispanic Non-Hispanic 

N % of total N % of total 

arrests for arrests for 

Hispanics Non-Hispanics 
Driving under 

influence 1^25'f8 19 1082327 17 



Liquor laws 19230 3 
Drunkenness 159^^33 21 



256080 II- 
7719^1 12 



Driving under 
influence 

Liquor laws 



Less than 18 years of age 

Hispanic Non-Hisp>anic 



N % of total 
arrests for 
Hispanics 



2'f99 
7399 



Drunkenness 178673 



1 
'^■ 
5 



N % of total 
arrests for 
Non-Hispcinics 



22633 

111351 

2«t96'f 



1 
7 
2 



Source of data: Crime in the United States, 1981 
(F.B.I., 1981). 



167 



Table 2: Alcohol-related Arrests per 100,000 

Population by Hispanic Origin; 1981. 



18 years of age and older 

Hispanic Non-Hispanic 

1712.2 7k2.(> 

Liquor laws 230.9 175.7 

Drunkenness 191^.9 529.7 



Driving under 
influence 



Less than 18 years of age 

Hispanic Non-Hispanic 

39.8 3't.2 

Liquor laws 117.8 168.3 

Drunkenness 138.0 37.7 



Driving under 
influence 



Source of data: Crime in the United States, 1981 
(F.B.L, 1981). 



168 



Table 3: Percentage of Admissions with Drug and Alcohol Disorders 

by Ethnicity and Type of Facility: United States, 1975 



Type of Facility 



Other White 



Black 



Hispanic 



Outpatient Psychiatric 
Services 

Inpatient Psychiatric Services: 
- State and County 



^.8 



8.6 



Source: American Public Health Association (1982). 



5.6 



Mental Hospitals 


31.5 


27.7 


38.8 


- Private Mental Hospitals 


10.6 


9.7 


18.3 


- Non-Federal General 








Hospitals 


10.^ 


10.8 


9.7 


PUBLIC 


15A 


8.^ 


12.3 


NON-PUBLIC 


8.9 


12.7 


7.0 



169 



Table *: Percentage of Hispanic Clients Receiving Treatment for Alcoholism 

on September 30, 1980. 
Selected States. 



1980 



1982 



States 


All 

Clients 


% 

Hispanics 


All 

Clients 


% 

Hispanics 


% Hispanic in 

State Population 


Arizona 


5,317 


I't 


4,^52 


15 




16 


California 


54,^82 


23 


37,5'f2 


23 




19 


Colorado 


8,626 


28 


9,7^1 


23 




12 


New Mexico 


2,553 


35 


3,136 


12 




37 


Texas 


11,617 


23 


8,100 


16 




21 


New York 


22,Wii- 


13 


2^,332 


13 




9 


Florida 


8,998 


5 


11,008 


6 




9 


Southwest 1 


82,595 


23 


62,971 


23 




20 


U.S. 


307,662 


11 


283,166 


9 




6 



Source: State Alcoholism Profile Information System - SAPIS (1981) amd Department 
of Health and Human Service (1983). 

Arizona, California, Colorado, New Mexico, Texas. 



170 



Table 5: Alcohol-Related Problems Among Hispanics as Reported by Selected 

Surveys in the U.S. (Percentages). 



Problem 


Cahalan & 

Room, 1971* 
(N = 96) 


Cahalan, 

1976 
(N = 61) 


Cahalan & 

Trelman, 1976 
(N = 80) 


Alcocer, 

1979 
(N = 603) 


ACCIDENTS 




2 






* 




1 






6 


DRUNK DRIVING 


* 






* 




* 






6 


POLICE 




t* 






* 




1 






't 


FRIENDS 




12 






7 




* 






5 


HEALTH 




* 






3 




3 






7 


MARRIAGE 




6 






12 




1^ 






6 


LOSING 

CONTROL** 




2 






- 




7 






5 


JOB 




6 






3 




4 






* 



* Not reported in a comparable way. 

** Reported as "afraid of losing control" by Alcocer 1979, and as "loss of 
control" by Cahalan and Treiman 1976, and by Cahalan and Room 197^*. 



171 



Table 6: Drinking Patterns by Sex. Percentages in 

Brackets are Standardized by Age. 







MALES 




FEMALES 






White 
(10*7) 


Black 
(*68) 


Hispanic 
(279) 


White 
(1280) 


Black 
(738) 


Hispanic 
(355) 


Abstainer 


11 (11) 


16 (18) 


I't (15) 


18 (18) 


29 (32) 


32 (33) 


Occasional 


9 (9) 


7 (8) 


6 (5) 


18 (18) 


19 (19) 


20 (21) 


Infrequent 


13 (1^) 


17 (16) 


17 (17) 


27 (27) 


23 (21) 


2t^ (24) 


Frequent 
Low Maximum 


20 (20) 


21 (21) 


16 (18) 


22 (21) 


1* (1^) 


1*^ (U) 


Frequent 
High Maximum 


26 (25) 


17 (16) 


21 (20) 


11 (12) 


9 (9) 


7 (5) 


Frequent 
Heavier Drinker 


21 (21) 


22 (21) 


26 (2^) 


It w 


6 (5) 


3 (3) 



X2 Males = 30.432, df = 10, p .001 
X2 Females = 76.800, df = 10, p .001 



172 



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173 



Table & Problem Type by Sex and Ethnicity. Percentage of 

Respondents Reporting Specific Problems. 



MALES 



FEMALES 



Spouse upset because of 
drinking 

Someone in the family upset 
because of drinking 

Friends or neighbors upset 
because of drinking 

Someone else upset 
because of drinking 

Drinking hcis had a harmful 
effect on friendships 
and social life 

Drinking has had a harmful 
effect on health 

Drinking hcis had a harmful 
effect on home life 

Drinking has had a harmful 
effect on work and 
employment opportunities 

Drinking has had a harmful 
effect on financial position 



White Black Hispanic 
(10*7) (*68) (279) 



13 



10 



10 



12 



10 



11 



17 



11 



12 



White Black 
(1280) (738) 



1 
3 
1 



2 
3 



Hispanic 
(355) 



1 
2 



174 



Table 9: Standardized Regression Coefficients for Selected 

Variables with Number of Drinking Problems 



Variables 


Whites 


Blacks 


Hispanic 


Number of 
drinks per month 


.286* 


.292* 


.^09* 


Frequency 

of drunkenness 


.268* 


.2if2* 


.083** 


Attitudes 


.06^* 


ns 


ns 


Male 


syji* 


ns 


.119* 


Age 


-.067* 


ns 


ns 


Housewife 


-.058** 


ns 


ns 


Unemployed 


ns 


ns 


.107** 


Total R2 


.27 


.25 


.26 



* F test: p .01 
**F test: p .05 
ns: not significant 



175 



Table 10: Attituctes Toward Alcohol Use. Percentage of Respondents 

"Basically Agreeing" by Sex and Ethnicity. 



MALES 



FEMALES 



White Black Hispanic White 

(10*7) (*68) (279) (1280) 



Black Hispanic 
(738) (355) 



It is all right for a 
woman to get drunk 
once in a while 



5^ 



36 



39 



37 



2H 



33 



It is all right for a 
man to get drunk 
once in a while 



56 



kH 



5k 



*0 



35 



^8 



Getting drunk is 
sometimes a good 
way to blow-off steam 


30 


28 


36 


15 


21 


Getting drunk is 
just an innocent 
way of having fun 


21 


28 


35 


10 


18 


A real man can hold 
his liquor 


5 


18 


Ik 


3 


8 



22 



22 



11 



People who drink 
have more fun than 
people who don't 

People who drink 
have more friends 
than people who don't 

A party isn't really a 
party unless alcoholic 
beverages are served 



23 



12 



19 



33 



21 



26 



33 



16 



17 



23 



13 



25 



26 



176 



Table 11: Knowledge About the Use and Effects of Alcoholic Beverages. 

Percentage of Respondents Giving the Correct Answer By Sex 

MALES FEMALES 

(279) (35^^) 

1. Alcohol is a stimulant that 
peps people up and makes 

them more alert (F) 80 79 

2. Drinking on an empty 
stomach can increase the 
speed that alcohol gets 

into your blood (T) 96 97 

3. Most people can drink about 
three cans of beer in one hour 

without getting high (F) 'f3 t^it 

k. A person weighing 160 pounds 
and someone weighing 120 
can drink the same amount 
of alcohol during the same 
time period and will be 
affected the same way (F) 68 57 

5. Alcohol can be an addictive 

drug (T) 93 96 

6. Alcohol is the drug most often 

involved in violent acts (T) 87 87 

7. Alcohol is the drug most often 

involved in accidents (T) 93 95 

8. Many serious diseases are 
related to drinking too much 

alcohol (T) It* 90 

9. About one out of five 
adults in California are 

non-drinkers (T) 'f9 'fS 

10. Most adults in California 
drink more than once a 

week (F) 8 11 

11. Calif ornians drink more than 
people in most other 

states (T) 52 f6 

12. It is legal for a 19 year 
old to drink beer in 

:alifornia (F) 81 69 



v^c 



13. It's against the law for a 
bartender or a liquor store 
clerk to sell alcoholic 
beverages to someone who is 
drunk (T) 81 73 



177 



Table 12: Perceptions of Community Problems as Very Important by Ethnicity* 

(in percents) 



Blacks Hispanics Whites 

(1206) (63'^) (232S) 

Drunk driving in your community ^^ 58 '^8 

Divorces and family troubles in your 

community due to drinking 25 

People in your community in poor health 

due to drinking 25 

The number of liquor stores and bars 

in your community 19 

Teenagers in your community drinking 32 

People in your community doing poor work or 

staying away from work due to drinking ... 19 

Alcoholic beverage containers being thrown 

into streets and yards in your community . . 40 

People standing around in groups and drinking in 
public places like parks or street corners 
in your community i^O '^0 22 



Source: Randolph, 1984. 



38 


29 


30 


21 


20 


I'f 


43 


33 


29 


16 


45 


36 



178 



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186 



Diabetes 



SUBCOMMITTEE ON DIABETES 



T. Franklin Will iamis, M.D., Chairperson 

Director 

National Institute on Aging 

Shirley P. Bagley, M.S. 

Assistant Director for Special Programs 

National Institute on Aging 

Maureen Harris, Ph.D., M.P.H. 

Director, National Diabetes Data Group Program 
National Institute of Arthritis, Diabetes, and 
Digestive and Kidney Diseases 

Robert Kreuzburg, M.D. 

Acting Associate Director, Office of Program Operations 

Indian Health Service 

Health Resources and Services Administration 

Lois Lipsett, Ph.D. 
Chief, Special Programs Branch 
National Institute of Arthritis, Diabetes, 
Digestive and Kidney Diseases 

Everett Rhoades, M.D. 

Director, Indian Health Service 

Health Resources and Services Administration 

Alex Sabatini 

Senior Operations Research Analyst 

Office of Human Development Services 

Robert Silverman, M.D., Ph.D. 
Chief, Diabetes Programs Branch 
National Institute of Arthritis, Diabetes, and 
Digestive and Kidney Diseases 

Staff Liaison: 

Frank Hamilton, M.D., M.P.H. 



189 



190 



REPORT OF THE 
SUBCOMMITTEE ON DIABETES 



191 



CONTENTS 

Chapter 1. The Problem 193 

Chapter 2. Diabetes In Black Americans 214 

Chapter 3. Diabetes In Native Americans 230 

Chapter 4. Diabetes In Hispanic Americans 254 

Chapter 5. Diabetes In Asian Americans 271 

Chapter 6. Prevention and Control 285 



The Subcommittee gratefully acknowledges Beatrice Jakubowsky for her 
valuable assistance In preparing this report. 



Chapter 1 
THE PROBLEM 



In 1980, diabetes mellitus was listed as the seventh leading cause of 
death in the United States by the National Center for Health Statistics (NCHS). 
However, official statistics for diabetes greatly underestimate the true 
impact of the disease on overall mortality and morbidity. Rather than dying 
from the disease itself, people with diabetes most often die from its long- 
term complications, such as heart disease, kidney disease, and stroke, which 
frequently are listed on death certif iciates as the cause of death. 

The serious complications of diabetes also are largely responsible for 
the high morbidity associated with diabetes. People with diabetes have twice 
as many heart attacks and about twice as many strokes as people who do not 
have diabetes. In adults, peripheral vascular disease associated wtih dia- 
betes accounts for half of all nontraumatic amputations each year. Twenty- 
five percent of kidney failure and 12 percent of new blindness are attributable 
to diabetes. Diabetes is a major risk factor in pregnancy, accounting for 
some 4,000 to 4,500 neonatal deaths each year and a high incidence of congeni- 
tal abnormalities, respiratory distress syndrome, prematurity, and other 
serious and life-threatening problems in newborn infants . 

Although there is no known cure for diabetes , current evidence supports 
the view that the careful control of diabetes, together with good general 
health and nutritional practices, can prevent, delay, or ameliorate some of 
these serious complications. 

Diabetes exemplifies the difference in health status between whites and 
minority groups. Although the problem is a national one that affects all 
segments of our population, blacks. Native Americans, Hispanic Americans, and 
Asian Americans suffer a disproportionate share of the disease, its effects, 
and the complications that arise from it. These minority groups generally 
have not had optimal access to continuing quality medical care in the past. 
As a result, over the past 50 years, they have accumulated a heavy burden of 
chronic disease (diabetes, hypertension, and obesity and their associated 
complications) that still adversely affects their health status. This 
situation in turn is reflected in increasing diabetes-related mortality, 
morbidity, and costs during the past 20 years. 

Table 1.1 shows the prevalence and relative risk of diabetes among whites 
and among the four minority groups discussed in this report. Age-adjusted 
rates for mortality from diabetes are 50 percent higher in nonwhites than in 
whites, according to NCHS. While the percentage of the white population 
with diabetes approximately doubled in the last two decades, the percentage 
of diabetic blacks has almost tripled. Other minority groups are similarly 
affected. In one Native American tribe, the Pima Indians, about half of the 
population over 34 years old has diabetes, and their risk of incurring the 
disease is more than 10 times that of the white population. Hispanic Ameri- 
cans are three times as likely as whites to have the disease. Although 
Americans of Japanese ancestry have not been as affected as other minority 



193 



groups, their diabetes has been out of proportion to their representation 
in the Nation as a whole. 

This report summarizes the nature of diabetes, its incidence and 
prevalence, its complications, and the mortality attributable to it. The 
report will describe what we know about the experience of diabetes for each 
of the four minority groups — blacks. Native Americans, Hispanic Americans, 
and Asian Americans. Statistics presented in this report show that diabetes 
is a major problem of national concern that disproportionately affects the 
four minority groups identified in this study. 

Types of Diabetes 

Diabetes mellitus comprises a heterogeneous group of disorders whose 
common characteristic is glucose intolerance. Diabetes occurs when the body 
cannot properly metabolize carbohydrates, fats, and proteins, resulting in 
abnormally high levels of glucose in the blood. Diabetes is a chronic disease 
that may develop slowly or as an acute metabolic crisis. 

There are several types of diabetes. Insulin-dependent diabetes mellitus 
(IDDM), also know as type I diabetes, may occur at any age but typically 
develops in childhood or young adulthood. It is associated with certain 
genetic markers. IDDM is characterized by low levels or a total absence of 
insulin, and people with this kind of diabetes must depend on injected insulin 
to maintain their lives. IDDM accounts for approximately 5 to 10 percent of 
the diabetic population in the United States, according to the National 
Diabetes Data Group (NDDG) . 

Noninsulin-dependent diabetes mellitus (NIDDM) , also know as type II 
diabetes, is the most common form of the disease, accounting for 90 to 95 per- 
cent of all cases. It most often affects adults (usually over the age of 40), 
seems to run in families, and is more common in women than in men and more 
common in nonwhites than in whites. People who develop the disease are often 
overweight. They may have high, normal, or low levels of insulin, but their 
ability to use it effectively is impaired. People with IDDM often can 
manage the disease through diet, weight control, and exercise, although some 
may require treatment with oral hypoglycemic agents or insulin. It has been 
estimated that up to 50 percent of NIDDM can be prevented through weight 
reduction and exercise. 

Gestational diabetes occurs only during pregnancy. In gestational dia- 
betes, blood glucose levels rise during pregnancy and revert to normal after- 
ward. Women who are older and overweight, have family histories of diabetes, 
and have a history of multiple unexplained miscarriages or unusually large 
babies are prone to gestational diabetes. The disease may affect both mother 
and fetus. Almost 90,000 babies are born each year to women who develop 
gestational diabetes. Women who have had this form of diabetes are at in- 
creased risk of NIDDM later in life. 



194 



Incidence and Prevalence 

Data on the Incidence and prevalence of diagnosed diabetes are derived 
primarily from statistics compiled by the National Diabetes Data Group and 
the National Center for Health Statistics. The National Health Interview 
Survey (HIS), sponsored by NCHS, collects data through regular interviewing 
of household members and represents the noninstitutionalized population of 
the United States. HIS does not break down data by type I and type II diabetes, 
NCHS also conducts the Health and Nutrition Examination Survey (HANES) , which 
periodically collects data from a probability sample of the population and 
from standardized direct medical examinations that include oral glucose- 
tolerance tests. 

The NDDG estimates that 10 million Americans have diabetes — 5.5 million 
with diagnosed diabetes and another 4.5 million with undiagnosed disease. 
In 1985, according to a new report of the National Diabetes Advisory Board, 
another 500,000 cases will be diagnosed, and 150,000 people will die from the 
disease and its complications. 

Tables 1.2, 1.3, and 1.4 provide statistics on the prevalence and inci- 
dence of diabetes in the United States in 1978. Table 1.2 shows the number 
of new cases of diabetes in 1978, and table 1.3 provides data on the incidence 
per 100,000 persons by age and sex. The number and rate of diagnosed diabetes 
in American blacks in 1979-81 are shown in table 1.4. Among persons, mostly 
elderly, living in long-terra care facilities , surveys indicate a diabetes 
prevalence of about 15 percent. 

Diabetes Mortality 

The National Center for Health Statistics develops disease-specific 
mortality rates by tabulating data on "underlying cause of death" and 
"multiple causes of death" as given on death certificates. Studies indicate , 
that diabetes is generally underreported on death certificates. This under- 
reporting of diabetes mortality is particularly true for older persons with 
multiple chronic conditions such as hypertension and heart disease. Because 
of this underreporting, the true toll of diabetes is believed to be much 
higher than officially reported. 

Table 1.5 shows the number of deaths in 1980 by age, race, and sex in 
which diabetes was reported as the underlying cause. Death rates per 100,000 
people are shown in table 1.6. The number of deaths in which diabetes was 
reported as the underljring or contributing cause in 1979 is shown by age, 
race, and sex in table 1.7, and table 1.8 presents the age-, race-, and sex- 
specific death rates per 100,000 in the general population. 

In general, a person's life expectancy at diagnosis of diabetes is dimin- 
ished by one-third. Mortality rates are higher in people who develop diabetes 
at a young age. A study of life insurance applicants revealed that the 
mortality rate in those who developed diabetes before 15 was 11 times higher 
than in the general population; in those who developed diabetes after age 40, 
the mortality rate was two to three times higher. After age 15, death rates 
among women with diabetes are lower than in their male counterparts. However, 



195 



the difference between men and women is smaller than the difference in the 
general population. Age-adjusted rates of mortality from diabetes in non- 
whites are approximately 50 percent higher than those in whites. 

Cardiovascular disease, kidney disease, and stroke are major causes of 
death in people with diabetes. In the population included in the Framingham 
Study, death from cardiovascular disease was 2.9 times more common in people 
with diabetes than in the general population. Death from renal disease is 
50 times more common in people with IDDM. 

Risk Factors 

Table 1.9 summarizes risk factors such as age, sex, race, genetic fac- 
tors, and obesity associated with IDDM, NIDDM, and gestational diabetes. 

* 

Age, Sex, and Race . Insulin-dependent diabetes occurs most frequently 
in children and adolescents, with the peak age of onset between 10 to 14 
years old. Both sexes are equally affected, and whites have a slightly 
higher incidence of IDDM than do other races. 

Noninsulin-dependent diabetes increases dramatically with age in both 
incidence and prevalence, which are 1.8 and 1.4 times, respectively, as high 
in women as in men. According to HIS statistics for 1979-81, the prevalence 
rate in white men is 2.1 percent and in white women is 2.4 percent; in black 
men, the rate is 2.4 percent and in black women is 3.6 percent. The percent- 
age of the Hispanic population estimated to be diabetic is 4.5 percent, and 
among Native Americans, the reported diabetes prevalence rate is 20 percent. 

Gestational diabetes increases in incidence with age and is not inde- 
pendently affected by race. 

Genetic Factors . IDDM is more likely to occur in persons with certain 
genetic markers or human leukocyte antigens (HLA). The risk is increased 3 
times in those with two DR3 genes, 5 times in those with two DR4 genes, and 
9.4 times in those with the combination DR3/DR4. 

NIDDM in whites is not associated with specific HLA types. Siblings 
of persons with this form of diabetes, however, incur a risk up to six times 
as great as that of siblings of age-matched people without diabetes. The 
risk in children of NIDDM patients is doubled. 

Gestational diabetes is more likely to occur in women with family 
histories of diabetes. 

Level of Physical Activity . Well-documented studies clearly show a 
correlation between low levels of physical activity and the development of 
noninsulin-dependent diabetes. Lack of physical activity, in fact, leads to 
the deterioration of glucose tolerance and a reduction in the level of insulin 
secretion, while exercise improves both. One population study among Native 
Americans demonstrated that the rate of diabetes was higher among sedentary 
individuals (7.9 percent) compared with more physically active individuals 
(2.8 percent). Because inactivity favors obesity, which is an important deter- 



196 



minant of the risk of NIDDM, exercise may diminish the risk of becoming 
diabetic because of the effects of exercise on obesity. 

Although exercise is probably a protective factor in NIDDM, there is 
no evidence that the level of physical activity is related to the develop- 
ment of insulin-dependent diabetes. 

Diabetes During Pregnancy . A considerable amount of clinical data show 
that serious complications are associated with diabetes and pregnancy. NDDG 
data show that infants of diabetic mothers experienced higher rates of mortality, 
prematurity, and congenital malformations than the infants of mothers without 
diabetes. Annually, about 10,000 babies are born to mothers with insulin- 
dependent diabetes. According to statistics from the National Center for 
Health Statistics, another 60,000 to 90,000 babies are born to women who 
develop glucose intolerance during pregnancy (gestational diabetes). 

Although epidemiologic studies of adverse outcomes in pregnancies in 
minorities are limited, minority populations appear to have excess mortality 
related to diabetes during pregnancy. A study in South Carolina showed that 
perinatal mortality among blacks was 3 times that of whites with diabetes and 
8.5 times that of whites without diabetes. Among Native Americans, the 
Pima Indians have been reported to have higher infant mortality rates asso- 
ciated with diabetes during pregnancy. The rate in Pimas is 3.8 percent 
compared with 0.28 percent for the general population. Although population 
studies among Hispanics show significant excess morbidity and mortality due 
to diabetes, little information about the prevalence of diabetes during 
pregnancy is available at the present time. Among all population groups, it 
has been well documented that meticulous control of blood glucose during 
pregnancy can prevent the complications of diabetic pregnancy, with the 
exception of congenital malformations. 

Environmental Factors . The impact of environmental factors on the 
development of diabetes remains uncertain. Environmental factors that have 
been implicated include diet, viruses, geographic location, and psychological 
stress. 

Some epidemiologic evidence from population studies among Native Americans 
and Japanese indicates that changes in diet over the past four decades may, 
in fact, account for the increased prevalence of diabetes among these popula- 
tions. Historically, the diets of Native Americans and Japanese were lower 
in calories and higher in fiber than their current diets. Certainly, diet 
has an important relationship to obesity, which has a strong association with 
NIDDM. 

A growing body of scientific evidence indicates that certain viruses may 
be etiologic agents in the development of IDDM. In addition, patients with 
new onset of insulin-dependent diabetes have been shown to have antibodies to 
pancreatic islet cells, suggesting an autoimmune response to an as-yet un- 
identified agent. 

Some current investigations are under way to assess the relationship of 
geographic location to the development of diabetes because the prevalence of 



197 



diabetes seems to increase with distance from the equator. With respect to 
environmental stress, the increased prevalence of diabetes among Native 
Americans and Japanese Americans may be attributed to the increased psycho- 
logical stress of social and cultural changes that have affected these people 
over the past four decades. 

Clearly, further research to clarify the impact of environmental factors 
in the development of diabetes in both the general population and minority 
populations is needed. 

Complications of Diabetes 

The true toll taken by diabetes is not limited to its direct effects. 
Table 1.10 shows the incidence and prevalence in 1980 of such acute and 
long-term complications as ketoacidosis, congenital malformations, stroke, 
coronary heart disease, peripheral vascular disease, blindness, end-stage 
renal disease (ESRD) , and amputations. Table 1.11 shows the risk factors for 
these complications, including the types of diabetes with which each is 
associated, the influence of age, sex, and race, and the level of importance 
of eight other factors. 

Risk factors for the complications of diabetes include hypertension, 
cigarette smoking, hyperlipidemia, hyperglycemia, inadequate education in 
self-management skills, and inadequate or poor access to medical care. 

Prevention 

Although a great deal is becoming known about the pathogenesis and preven- 
tion of diabetes and its complications and successful techniques for improved 
diabetes management have been developed, the information has not always been 
communicated to people with diabetes and to the providers of health care 
services. 

We know that obesity has a major association with NIDDM, and yet it 
remains a national epidemic. Many people with diabetes do not know the 
warning signs of ketoacidosis and lack self-management skills In monitoring 
for this condition. Many women with diabetes fail to achieve euglycemia 
before and during pregnancy, and many cases of gestational diabetes are not 
diagnosed and treated. Many providers of health care do not prescribe self 
blood glucose monitoring for those patients who might benefit from this 
approach, and glycosylated hemoglobin tests to monitor glycemic control are 
not performed by attending physicians as consistently as would be desirable. 

Studies indicate that only three-fourths of those people with diabetes 
and hypertension are treated for the latter condition, and only half have 
adequately controlled blood pressure. Physicians check the blood pressure of 
diabetic patients during only 67 percent of their office visits. More than 
1 million people with diabetes smoke cigarettes. Fewer than 50 percent are 
given yearly examinations for diabetic retinopathy. We know that the daily 
demands of a rigorous medical regimen and fear of devastating complications 
produce severe stress on patients and their families, yet emotional and 



198 



psychological support often is not available to them from health care pro- 
viders and society in general. 

In terms of human suffering and economic issues, the cost of the failure 
to put to use what is known about controlling diabetes is enormous. A very 
large proportion of these costs could be saved with more effective communica- 
tions of new knowledge and techniques to health care professionals and to 
diabetic patients and their families. A large share of these costs is borne 
by the four minority groups hardest hit by the disease. The next four chap- 
ters will review the problem of diabetes as it affects these groups. 



199 



SOURCES 

Etzwiler PD: Who's teaching the diabetic? Diabetes 16:111-117, 1967. 

Watkins JD, Williams TF, Martin DA, Hogen MD, Anderson E: The clinical 
picture of diabetic control studied in four settings. Am J Public Health 
57:452, 1967. 

Williams TF, Anderson E, Watkins JD, Coyler: Dietary errors made at home 
by patients with diabetes. J Am Diet Assoc 51:19, 1967. 

Miller LV , Goldstein J: More efficient care of diabetic patients in the 
country-hospital setting. N Engl J Med 285:1388, 1972. 

Runyan JW Jr., Vander Zwaag R, Joyner MB, et al. The Memphis diabetes 
continuing care program. Diabetes Care 3:382-386, 1980. 

Davidson JK: Educating diabetic patients about diet therapy. Int Diabetes 
Fed Bull 20:1, 1975. 

Knowler WC, Bennett PH, Pettitt DJ , Savage P J : Obesity and diabetes in Pima 
Indians: the effects of parental diabetes on the relationship of obesity and 
the incidence of diabetes. In Melish JS, Hanna J, Baba S, eds., Genetic 
Environmental Interaction in Diabetes Mellitus, Excerpta Medica, Amsterdam, 
1982, pp 95-100. 

Conference on Financing Quality Health Care for Persons with Diabetes, Oct. 
22-24, 1984, Airlie House, Airlie, Virginia. 

Herman WH, Teutsch SM, Geiss LH: Carter Center Health Policy Project — Closing 
the Gap. Health Problem: Diabetes Mellitus, Nov. 26-28, 1984, Atlanta, Georgia. 

Davidson JK: The Grady Memorial Hospital diabetes unit ambulatory care pro- 
gram. In Assal J PH, Assal M, Berger N, Canivet Gay & J, eds., Excerpta 
Medica, Amsterdam-Oxford-Princeton, 1982, pp 286-297. 

Davidson JK: The Grady Memorial Hospital programme in diabetes in epidemio- 
logical perspective. In Mann JI, Pyorala K, Teuscher A, eds., Churchill 
Livingstone, Edinburgh, 1983, pp 332-341. 

Vander Zwaag R, Runyan JW Jr., Davidson JK, Delcher HK, Mainzer I, Baggett 
HW: A cohort study of mortality in two clinic populations of patients with 
diabetes mellitus. Diabetes Care 6:341-346, 1983. 

Davidson JK, Vander Zwaag R, Cox CL, Delcher HK, Mainzer I, Baggett H, Runyan 
JW: The Memphis and Atlanta continuing care programs for diabetes. II. Com- 
parative analyses of demographic characteristics, treatment methods, and 
outcomes over a 9-10 year follow-up period. Diabetes Care 7:25-31, 1984. 

Davidson, JK, Runyan JW: The efficacy of patient education in the Memphis 
and Atlanta Continuing Care Programs for diabetes. Diabetes Care (submitted 
for publication, 1984). 



200 



Davidson JD: Non-insulin dependent diabetes mellitus. In Clinical Diabetes 
Mellitus: A Problem-Oriented Approach, Davidson JK, ed., Thieme-Stratton, 
Inc., New York, 1985. 

Malhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L, Kunz A, 
Schernthaner G, Scholz V, Voss HE: Bicentic evaluation of a teaching and 
treatment programme for type I diabetic patients. Improvement of metabolic 
control and other measures of diabetes care for up to 22 months. Diabetologia 
25:470-476, 1983. 

Diabetes in America: Diabetes Data Compiled 1984. Harris MI, Hamman R, 
eds., GPO, Washington, D.C., 1985. 

NHANES II, Harris, MI. National Diabetes Data Group, unpublished data. 

Bennett P. Increasing prevalence of diabetes in American Indians. In 
Diabetes 1979. Excerpta Medica. 

National Diabetes Advisory Board: 1985 Annual Report, Bethesda, Md., U.S. 
Public Health Service, National Institutes of Health, NIH Publication No. 
85-1587, May 1985. 



201 



Table 1.1 

AGE-ADJUSTED PREVALENCES AND RELATIVE RISKS OF DIABETES 
BY TYPE OF DIABETES AND RACE, UNITED STATES 



White 



Black 



Hispanic 



Native 

American 

(Pima) 



Japanese/ 
American 



Type I diabetes 

Prevalence per 
100,000 

Relative risk* 

Type II diabetes 

Prevalence per 
100,000 

Relative risk* 



160l 



1.01 



130l 



0.8 



2,3005 2,9005 



1.0 



1.3 



1502 



0.9 



7,2006 



3.1 



<1.03 



24,8007 



10.8 



<1.0^ 



1.48 



*Risk compared to US white population. 

Relative risk is a statistical association between the presence of a risk 
factor and the chance of having a particular disease brought about by the 
factor's presence. 

Relative risk is a ratio, with the numerator being expressed as number of pairs 
for which the case member exhibits the risk factor while the control does not: 
the denominator is number of pairs for which the control member exhibits the 
risk factor while the case member does not. 

SOURCES: 

^LaPorte RE: The prevalence of insulin-dependent diabetes mellltus. In 
Diabetes Data-Compiled 1983, National Diabetes Data Group, NIH, in press. 

^Young W, Murphy S, Marcus P, Harmon R: Prevalence of diabetes and incidence 
of related acute complications in Denver area school-age children. In Pro- 
ceedings of the 6th Annual CDC Diabetes Control Conference, Centers for 
Disease Control, 1983. 

^Sieves ML, Fisher JR: Diabetes in Native Americans. In Diabetes Data- 
Compiled 1983, National Diabetes Data Group, NIH, in press. 

^Fujimoto WY: Diabetes in Asian Americans. In Diabetes Data-Compiled 1983, 
National Diabetes Data Group, NIH, in press. 

^Harris M: The prevalence of noninsulin-dependent diabetes mellltus. In 
Diabetes Data-Compiled 1983, National Diabetes Data Group, NIH, in press. 



202 



Table 1.1 (continued) 
Sources (continued) 

^Stern MP: Diabetes In Hlspanlcs. In Diabetes Data-Compiled 1983, National 

Diabetes Data Group, NTH, in press. 
^Knowler WC, Pettitt OJ, Savage PJ, Bennett PH: Diabetes Incidence in Pima 

Indians: Contributions of obesity and parental diabetes. Am J Epidemiol 

113:144-156, 1981. 
'^Bennett CG, Tokuyama GH, Bruyers PT: Health of Japanese Americans in Hawaii. 

Public Health Reports 78:753-62, 1963. 



203 



Table 1.2 

NUMBER OF NEW CASES OF DIABETES IN THOUSANDS 
BY AGE AND SEX, UNITED STATES, 1978 



Age Men Women Total 

13* 
109 
107 
135 
206 
570 

*Figure does not meet standards of reliability or precision. 

Source: National Diabetes Data Group, NIH, from the National 
Health Interview Survey, 1978. 



>25 


— 


13* 


25-44 


64 


45 


45-54 


21* 


86 


55-64 


32* 


103 


65+ 


80 


126 


Total 


197 


373 



204 



Table 1.3 

INCIDENCE OF DIABETES PER 100,000 
BY AGE AND SEX, UNITED STATES, 1978 



Age Men Women Total 

14* 
192 
466 
661 
907 
267 

♦Figure does ndt meet standards of reliability or precision. 

Source: National Diabetes Data Group, NIH, from the National 
Health Interview Survey, 1978. 



>25 


— 


29* 


25-44 


233 


153 


45-54 


189* 


724 


55-64 


332* 


955 


65+ 


859 


941 


Total 


191 


337 



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210 



Table 1.9 
SUMMARY OF RISK FACTORS FOR DIABETES 











HLA/ 






Age 


Sex 


Race 


Family 
History 


Obesity 


Type I diabetes 


Maximum 


F = M 


White > 


HLS 


No 


mellitus 


at 10-14 




other races 


DR3/DR4 






years 




RR = 1.1 


RR = 9 




Type II diabetes 


Increases 


F > M 


Other races 


Family 


Yes 


mellitus 


with age 


RR = 1.4 


> white 
RR = 1.3 


history 
RR = 2 


RR = 3 


Gestational 


Increases 


F only 


White = 


No 


Yes 


diabetes mellitus 


with age 




other races 




RR = 2 



Source: Table compiled by S. M. Teutsch, Centers for Disease Control, 
September 1984 (unpublished document). 



211 



Table 1.10 

ESTIMATED NUMBERS OF INCIDENT AND PREVALENT CASES 

OF COMPLICATIONS OF DIABETES, 

UNITED STATES, 1980 



Incident Cases 



Prevalent Cases 



Diabetic ketoacidosis 

Serious congenital 
malformations 

Stroke 

Coronary heart disease 

Peripheral vascular 
disease 

Blindness 

End-stage renal 
disease 

Amputation 



75,000 

850 
23,000 
85,000 

41,000 
5,800 

4,000 
31,000 



320,000 
650,000 

497,000 
40,000 

7,600 
71,000 



Source: National Diabetes Data Group, NIH. 



212 



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213 



Chapter 2 
DIABETES IN BLACK AMERICANS 



Until 1940, diabetes mellitus was less common in the black population 
than in the general population. Today, the prevalence of noninsulin-dependent 
diabetes is 33 percent higher in black Americans than in the white population. 
Moreover, diabetes is the third leading cause of death from disease in blacks, 
exceeded only by heart disease and cancer. According to 1980 data from the 
National Center for Health Statistics, 3.2 percent of the approximately 27 
million blacks in this country (more than 800,000 people) have diagnosed 
diabetes, and another 4 percent (over 1 million) are thought to have undiagnosed 
diabetes. 

The majority of blacks with diabetes in the United States appear to have 
noninsulin-dependent diabetes. Reliable estimates of the prevalence of insulin- 
dependent diabetes in blacks are not available. Insulin-dependent diabetes 
probably is less common in blacks than in whites in this country, but more 
common than in African blacks. How much of a prevalence differential there 
is between blacks and whites in the United States is uncertain. Estimates 
of IDDM incidence in the U.S. black population compared to the white population 
have ranged as high as 5 to 1, although most studies suggest a ratio of 2 to 
1 or less. 

Findings from various population-based studies of the prevalence of 
diabetes in adult black Americans are summarized in table 2.1. Although 
early studies conducted before 1960 relied on medical histories to identify 
diabetes, and consequently underreporting was likely, the prevalence of 
diabetes in black Americans was thought to be quite low in the first half of 
this century. Black Americans are a minority group that has undergone both 
migration and genetic admixture over the past 300 years. Comparison with 
U.S. whites and African blacks may provide an explanation for the increased 
prevalence of diabetes noted since 1960 and the possible etiology and natural 
history of the disease among blacks. 

Published studies in Africa, although difficult to use for comparative 
purposes because they are based on different study methods, suggest that the 
rate of diabetes in black Africans is lower than in black Americans. The 
lower prevalence of diabetes among African blacks has been attributed to the 
fact that clinical studies in Africa have included a younger and more rural 
population. However, there is some evidence suggesting that the prevalence 
of diabetes in urban African communities is similar to that in U.S. blacks. 
The difference was noted to be greater among urban African women than among 
rural inhabitants. 

Incidence and Prevalence 

The first national estimates of the prevalence of diabetes in blacks are 
based on data collected by the Army from World War I draftees 18 to 45 years 
old. The Army reported a diabetes rate of 13 per 1,000 among blacks from 
rural areas, 0.15 among southern rural whites, and 0.45 among northern rural 



214 



whites. By the time of World War II, Selective Service reports indicate that 
the rate of diabetes in blacks was 1.9 per 1,000 in 1943 and 0.8 per 1,000 in 
1944. Although these rates are higher than those of World War I for blacks, 
both figures were still substantially lower than the white rate of 3.0 per 
1,000 reported during World War II. 

Twenty years later, the rate of diabetes in blacks began to climb dra- 
matically. National Health Interview Surveys indicate that between 1963 and 
1979-81, diabetes increased by 175 percent in blacks compared with 106 percent 
in whites'. The increase in part reflects the increase in the diagnosis of 
latent cases. However, even when allowance is made for this effect, the rise 
remains significant. 

Several community-based surveys, summarized in table 2.2, show mixed 
findings. A study in Evans County, Georgia, conducted between 1960 and 1962 
found rates of diabetes of 3.0 percent in black males and 6.6 percent in 
black females. The rate in black females was higher than that of white 
females, while black males exhibited a lower rate of diabetes than white 
males. 

In a screening program conducted in Cleveland, Ohio, from 1964 to 1967, 
the rate of diabetes was found to be slightly higher in nonwhites compared with 
white volunteers. Blacks showed a lower prevalence of diabetes in two studies 
conducted in 1973 in Chicago, Illinois, and in northern California. The Chicago 
study, conducted in an industrial population, was based on medical histories 
and screening tests. The age-standardized prevalence of diabetes was found to be 
lower in both black men and women than in white men and women. Black men and 
women in the Kaiser-Permanente Health Plan in northern California showed 
significantly fewer instances of blood-glucose levels higher than 170 mg/dl 
than whites did 1 hour after glucose challenge. 

The majority of the studies summarized in table 2.2 have found higher rates 
of diabetes in black women than in black men. These studies also show that 
the prevalence of diabetes in black men and women increases with age, as it 
does in whites, but the age of peak onset in blacks may be lower. 

Undiagnosed Diabetes . As always, data on undiagnosed diabetes must be 
considered in the light of the high estimates of the prevalence of latent 
diabetes. Estimates of latent or undiagnosed diabetes are not included in 
the results of most studies. Table 2.3 demonstrates the significance of 
this problem. The study by Harris and Haddon, which has not yet been published, 
is based on fasting 75 g oral glucose tolerance tests in persons who had no 
medical history of diabetes. The results showed that 3.1 percent of this 
population had undiagnosed diabetes, that rates for black males and females 
were almost 1.5 times as high as rates for white males and females, that 
black females were much more heavily affected than black males after age 54, 
and that the prevalence in general increases with age. Rates in black women 
and black men were 4.7 and 3.7 percent, respectively. 

Prevalence of Diabetes in Black Youth . Table 1.1, in chapter 1, which 
is based on data compiled since criteria were established to distinguish 
between insulin-dependent and noninsulin-dependent diabetes, shows the 



215 



overall prevalence and relative risk of both types of diabetes in whites and 
in blacks and three other minority groups. Although the risk of NIDDM in 
blacks is 30 percent higher than in the white population, the risk of IDDM is 
far lower in blacks than in whites. 

Various studies conducted since 1928 have consistently shown that diabetes 
is less prevalent in young black Americans than in young whites (table 2.4). 
This observation, however, is based on studies that were for the most part 
confined to samples from clinics and are of doubtful accuracy. A study con- 
ducted in 1942 among outpatients in a clinic in Harlem found that only 0.8 
percent of 639 blacks with diabetes were in the 10 to 19 age group. The same 
age group included 1.9 percent of 106 white people with diabetes. A small 
study at Charity Hospital in New Orleans, Louisiana, found a nearly equal 
racial distribution of diabetes among 31 patients under 12 years of age, 
although 80 to 85 percent of the hospital's total patient population was 
nonwhite. Among all the new admissions for diabetes to St. Louis Children's 
Hospital between 1960 and 1970, the rate of diabetes in black children was 
less than 35 percent of the rate in white children. 

No national population survey has had sufficient sample sizes to determine 
accurately the prevalence of diabetes in children in this country. The Health 
Interview Survey for 1964-65 showed that 8.3 percent of the sample popu- 
lation of white people with diabetes was under 25 years old at diagnosis and 
4.6 percent under 15 years old. Of the nonwhite groups with diabetes, 3.4 
percent of the sample population was under 25 years old, with 0.3 percent 
under 15. However, because this type of estimate is dependent on the number 
of diabetes patients in the older age group, it cannot be used as a direct 
measure of comparative prevalence. In 1973, the HIS found a prevalence of 
diabetes of 1.2 per 1,000 in nonwhites younger than 17 years old and 1.4 per 
1,000 in whites. In all of these surveys, the nonwhite sample was too small 
for reliability. 

A study of the occurrence of long-term childhood illness in Erie County, 
New York, was based on a review of hospital and private medical records from 
1964 to 1972. The study found a prevalence of diabetes in blacks 16 years of 
age and younger of 29.5 per 100,000 — about half that of white children. A 
similar ratio was found in a mail survey of all Michigan school districts in 
1973. 

Studies of the incidence of diabetes in American black children also have 
been conducted in Pennsylvania and Alabama. The Pittsburgh IDDM Registry, 
which is based on a review of hospital records and surveys of pediatricians, 
found that new cases of diabetes occurred in white children in Allegheny 
County more frequently than in nonwhite children. The difference persisted 
when incidence rates were compared within socioeconomic groups. 

In short, sufficient data have not been collected to arrive at national 
estimates of the sex- and age-prevalence of diabetes in black children in the 
United States. Additional studies need to be undertaken, including studies of 
urban and rural populations in all sections of the country, to develop reliable 
statistics on the incidence and prevalence of IDDM in blacks. 



216 



Mortality 

Since World War II, the death rate from diabetes has consistently been 
higher for blacks than for whites (table 2.5). Moreover, mortality from 
diabetes in black females has been much higher than in black males. This 
finding has held even though the female-to-male ratio has fallen from 2:1 in 
1950 to 1.2:1 in 1980. Although the ratio has decreased in both races, the 
female-to-male ratio has consistently been higher in blacks. 

Table 2.6 shows that mortality attributed to diabetes increases with 
age in whites and blacks. Until recently, the rate peaked at younger ages in 
nonwhites, an effect attributed to the shorter lifespan among nonwhites and 
to a conjectured earlier onset of disease. 

Complications 

Few studies have examined the prevalence of diabetic complications in 
blacks in the United States. Even fewer have directly compared blacks with 
whites, controlling for duration of the disease. Studies based on mortality 
rates alone fail to take into consideration differences in incidence, age of 
onset, medical care, education, socioeconomic status, and interaction with 
hypertension, which occurs at a high rate in the black population. 

Macrovascular and Microvascular Disease . There is some evidence that 
black diabetes patients are more likely than blacks without diabetes to 
develop macrovascular and microvascular disease. As in whites, the prevalence 
of these complications increases with the duration of disease. The great 
variation found in the rate of macrovascular disease in blacks, however, 
suggests that diabetes and race alone are not sufficient etiological factors. 
As in whites, there is some question whether atherosclerosis in blacks is 
directly related to diabetes. 

Even the relative prevalence of macrovascular disease in blacks as 
compared to whites is in question. Most reports have suggested that myocardial 
infarction is less frequent among black Americans than among white Americans. 
However, as in the white population, heart disease is more likely to develop 
in blacks who have diabetes. The University Group Diabetes Study found that 
the percentage of deaths attributable to cardiovascular disease was lower in 
blacks with noninsulin-dependent diabetes than in whites with NIDDM. 

Retinopathy . Data from the Blindness Registry suggest that retinopathy 
is more prevalent in black people with diabetes than in white people with 
diabetes. The age-standardized prevalence of blindness secondary to diabetic 
retinopathy is more than twice as high in nonwhites as in whites (13.6/100,000 
as opposed to 5.9/100,000). Rates are consistently higher in both black males 
and black females, with the rate in females almost three times that of males. 

Other Complications . Although there is little published information 
about the incidence and prevalence of cerebrovascular disease, peripheral vas- 
cular disease, nephropathy, and neuropathy in blacks, the severity of these 
complications of diabetes may be higher among blacks than whites. Cerebrovas- 
cular disease appears to be more prevalent in blacks with diabetes than in 



217 



the general population. End-stage renal disease secondary to diabetic ne- 
phropathy is 3.3 times as high in blacks as in whites, according to the Michigan 
Kidney Registry. In one of the few direct comparisons between black, adults 
and white adults with diabetes, there was no significant difference in the 
presence of carotid-artery occlusive disease. 

Hypertension 

Hypertension is more prevalent in black Americans than in white Americans, 
and the association between hypertension and diabetes in the black population 
is more common than would be expected. In a study of employed volunteers in 
Chicago, however, after adjustment for blood pressure, cholesterol, and 
smoking, the rate of cardiovascular disease in black people with diabetes was 
lower than in those without the disorder. 

Prevention 



Exemplary programs that provide continuing outpatient diabetes care to 
populations more than 80 percent black have operated in Memphis, Tennessee, 
since 1962 and in Atlanta, Georgia, since 1968. Both programs are described 
in detail in chapter 6. Both use a team approach in treatment and in education, 
and both offer patients immediate access to professional staff members either 
by telephone or by drop-in visits. 

A major goal in both programs is to prevent or delay the development and 
progression of the complications of diabetes. The Memphis and Atlanta projects 
offer a prevention-oriented program of early detection, therapy, and continuing 
followup care. A basic assumption is that a preventive approach to diabetes 
and its complications is more effective in terms of both therapeutic effects 
and cost control. The results support the assumption: The Atlanta program 
has saved its sponsors an estimated $11 million in costs; the Memphis program, 
which has proved similarly cost effective, has seen reductions in hospitaliza- 
tions, diabetic ketoacidosis, and amputations. In both programs, more than 
70 percent of the participants have exhibited decreased plasma-glucose levels. 



218 



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Shafer SQ, Bruun B, and Richter RW. Brain infarction risk factors in black 
New York City stroke patients. J Chronic Dis 27:127-33, 1974 

Stamler J, and Lilienfeld A. Primary prevention of the atherosclerotic 
diseases. Circulation 42:A55A-95, 1970. (1,449 males and 2,334 females 
were included in this study.) 

Thomas WA, Blache 0, and Lee KT. Race and incidence of acute myocardial 
infarction. Arch Intern Med 100:423-29, 1957 

U.S. Department of Commerce. Bureau of the Census. 1980 Census of the 
Population, May 1981 

Weisse AB, Abiuso PD, and Thind IS. Acute myocardial infarction in Newark, 
NJ: A study of racial incidence. Arch Intern Med 137:1402-05, 1977 

Wells SJ, Roseman JM, and Boshell B. Summary of first year results of the 
first state registry of insulin dependent diabetes mellitus. Diabetes 29: (2)79- 
A, 1980 

West KM. Epidemiology of Diabetes and its Vascular Lesions. New York, 
Elsevier, 1979 

Wicks ACB, and Jones JJ. Insulinopenic diabetes in Africa. Brit Med J 1:773- 
76, 1973 

Zeidler A, Loon J, Frasier SD, Kumar D, Penny R, and Terasaki P. HLA-DRW 
antigens in Mexican-American and black patients. Diabetes 29:247-50, 1980 



222 



Table /.i 

POPULATION-BASED STUDIES ON THE PREVALENCE OF DIABETES* 
IN UNITED STATES BLACK ADULTS 



Reference 



Year 



Age 
(Years) 



Percent Diabetic 



Male 



Female 



Both 



Comments 



U.S. military draftees or registrants 

a 1924 18-45 0.015 — 



1943 



1944 



18-45 0.19 — 



18-45 0.08 



Kaclonal health surveys of Che U.S. population 
d 1960-62 18-79 



• 


1963 


All 






1.17 


• 


1964 


All 






1.27 


f 


1964-65 


All 


0.84 


1.78 


1.38 






<45 


0.24 


0.31 


0.28 






45f 


2.96 


6.86 


5.02 


• 


1965 


All 






1.38 


• 


1966 


All 






1.46 


• 


1967 


All 






1.69 


• 


1968 


All 






1.70 


• 


1973 


All 






2.47 


• 


1975 


All 
17-44 
45-64 
65«- 


2.18 


3.50 


2.89 
1.44 
8.72 
11.44 


• 


1976 


All 


2.26 


3.30 


2.82 


• 


1978 


All 


2.09 


3.61 


2.91 






15-44 


0.63 


1.12 


0.90 






45-64 


5.4 


10.8 


8.3 






65-84 


12.9 


14.2 


13.7 


g 


1976-80 


20-74 


4.6 


5.9 


5.2 






20-74 


4.0 


4.6 


4.4 


• 


1979 


All 


2.26 


3.84 


3.10 


• 


1980 


All 


2.71 


3.96 


3.38 



1981 



All 



2.64 



3.66 



3.19 



Black male WW I draftees rate 
much lower than white male 
rate 

Black male WW II military 
registrants rate less than 
white male rate 

Black male WW II military 
registrants rate less than 
white male rate 



Black men had slightly but 
significantly higher blood 
glucose values. Black women 
had poorer GTT but not when 
stratified on education. 

Black/white - 1.0 

Black/white - 1.0 

Black/white - 1.1 



Black/white - 1.1 
Black/white -1.0 
Black/white -1.1 
Black/white - 1.0 
Black/white - 1.2 
Black/white - 1.3 

Black/white - 1.2 

Black male /white male - 1.0; 
Black female/white female • 
1.3 



Diagnosed diabetes 
Undiagnosed diabetes; see 
Table 3 for detail 

See Harris, Diabetes in 
America (in press). 

See Harris, Diabetes In 
America (in press). 

See Harris, Diabetes In 
America (in press). 



223 



Table 2.1 (continued) 











A«e 


Percent Diabetic 




Reference 


Year 


(Years) 


Hale 


Female 


Both 


Cotsnents 


State 


(urveya 














h 




Mich. , 


1980 


All 


6.5 


10.1 


8.8 


Black/white - 1.7; higher 






1980 




18-34 


3.0 


3.2 


3.1 


than white rate for all age- 










35-44 


3.2 


6.4 


5.5 


sex groups except 65+ females 










45-64 


11.1 


22.3 


17.8 












65+ 


12.2 


13.4 


13.0 




1 




Calif. 


, 1979 


18+ 






5.3 


Black/ white •1.3 






1983 




18+ 


4.7 


6.8 


5.8 


Black/white •1.9 


i 








18-44 
45-64 
65+ 






0.7 
U.3 
22.7 




k 




Ala.. 
1982 




18+ 


8.9 


8.4 


8.6 


Black/ white • 1.6 



Cooaunlty-based surveys 

1 Evans 40-69 
Co. , Ga. , 
1960-62 



3.0 



6.6 



Rortham 

Calif., 

1964-68 

Chicago , 

111., 

1973 



15+ 



Adults 



9.4 



3.1 



5.3 



2.3 



— Baalth aalntenancc 

organization population 



— Industrial population 



*Dlab«tes was ascertained by previous aadleal history In all studies axcapt 1) tha 
1976-80 U.S. study, where a 75-graa oral glucose tolerance test waa used to detect 
undiagnosed diabetes: 2) the Cleveland study, where casual blood glucose waa aeaaured; 
and 3) the Northern California study, where dlabetaa waa defined aa 1-hour post- 
glucose >170 ng/dl. 



REFERENCES 



Eaarson, H, and U> Larlaore. Diabetes ■•llltus: A contribution to its epldeal- 
ology baaed chiefly on aortallty statistics. Arch Int Had 34:585-630, 1924. 

Selective Service System National Headquarters. Causa of Rajcctlon and Incidence 
of Defects. Local Board Examinations of Salactive Service Registrants in 
Peacetime. Medical Statistics Bulletin Ho. 2. Vaahlngton, D.C.: Tha Agency, 
Auguat 1, 1943. 

Selective Service System. Physical Examinations of Selective Service Registranta 
during wartime. Medical Statistics Bulletin Ho. 3. Waahlogton, D.C.: Tha 
Agency, November 1, 1944. (Nine million mala military registrants ware included). 

National Center for Haalth Statistics. The One-Hour Oral Glucoaa Tolerance Test. 
Vital and Health Statistics, Series 2, Number 3, July 1963. Glucose Tolerance 
of Adults, United Statea, 1960-62. Vital and Health Statistics, Seriaa 11, 
Number 2, Hay, 1964. Blood Glucose in Adults. Vital and Health Statistics, 
Series 11. Number 18, September, 1966. 

Drury, T. National Center for Health Statistics. Unpubllahad data from tha National 
Health Interview Surveys. 

National Center for Health Statistics. Differentials in Haalth Charaet aria tics by 
Color, United States, 1965-67. Vital and Health Statistics, Series 10, Number 
56, October, 1969. 

Harris, H, and U Haddon. National Diabetes Data Group. Prevalence of diabetes 
in the U.S. National Health and Nutrition ExaoUnation survey, 1976-80. In 
preparation. 

Halpem, M, DL Dodson, and J Beaaley. Diabetes In Michigan: 1980 Survey Results. 
Michigan Department of Public Health (R-908), September 1983. 

Dunbauld, S. Diabetes among California Hlspanlcs 1979-1980. Data Matters, 
California Center for Health Statistics (83-05079), 1983. 

California Department of Health Services. Hypertension Control Program. Hyper- 
tension Survey, 1982-1983. Unpublished data. (Black sample size • 224.) 

Mauser, M, S Jones, J McVay, U Louv, and J Roseman. Telephone survey of risk 
factors In Alabama, 1982. Unpublished data. (Black sample size > 161.) 

Deubner, DC, WE Wilkinson, MJ Helms, HA Tyroler, and CG Hamas. Logistic model 
estimation of death attributable to risk factors for cardiovaacular diseases In- 
Evans County, Georgia. Am J Epidemiol 112:135-43, 1980. (338 males and 396 
females were Included tn this study.) 

Dales LC, AB Slegelaub, R Feldman, GD Friedman. CC Seltzer, and MF Collen. Racial 
differences In serum and urine glucose after glucose challenge. Diabetes 23:327-32, 
1974. (5,337 males and 7,338 females were Included In this study.) 

Cooper R, K Liu. J Stamler, et al. Prevalence of diabetes and associated risk factors 
In blacks and whites: The Chicago Heart Association Detection Proiect In Industry. 
Unpublished data. 



224 



Table 2.2 
FEMALE-TO-MALE RATIOS AMONG UNITED STATES BLACKS WITH DIABETES 















Female/ 


Location 






Reference 


Year 


Group 


Male Ratio 


New York, N.Y. 






a 


1931 


Clinic patients 


3.5 


New York, N.Y. 






b 


1942 


Clinic patients 


4 


Oklahoma 






c 


1943 


Clinic patients 


5 


Nashville, Tennes 


see 


a 


1959-60 


Clinic patients 


3 


Evans County, 


Geo 


rgia 


e 


1960 


Population sample 


2.2 


Northern Calif 


orn 


ia 


f 


1964-68 


Health maintenance 
organization 


0.6 


Chicago 






g 


1973 


Industrial population 


0.8 


United States 






h 


1979-81 


Population sample 


1.5 


Michigan 






i 


1980 


Population sample 


1.6 


Alabama 






J 


1982 


Population sample 


0.9 


California 






k 


1983 


Population sample 


1.4 



REFERENCES 



a. 
b. 

c. 

d. 



J. 
k. 



Leopold, EJ. Diabetes in the Negro race. Ann Int Med 5:285, 1931. 
Altschul, A, and A Nathan. Diabetes mellitus in Harlem Hospital outpatient 

department in New York. JAMA 119:248-52, 1942. 
Cameron, PB. Observations on the Negro diabetic. J Okla St Med Assoc 36:517, 1943. 
Anderson, RS, A Ellington, and LM Gunter. The incidence of arteriosclerotic 

heart disease in Negro diabetic patients. Diabetes 10:114-18, 1961. 
Deubner, DC, WE Wilkinson, MJ Helms, HA Tyroler and CG Hames. Logistic model 

estimation of death attributable to risk factors for cardiovascular disease in 

Evans County, Georgia. Am J Epidemiol 112:135-43, 1980. (338 males and 396 

females were included in this study.) 
Dales LG, AB Siegelaub, R Feldman, GD Friedman, CC Seltzer, and MF Collen. Racial 

differences in serum and urine glucose after glucose challenge. Diabetes 23:327- 

32, 1974. (5,337 males and 7,338 females were included in this study.) 
Cooper, R, K Liu, J Stamler, JA Schoenberger, RB Shekelle, P Collette, and S 

Shekelle. Prevalence of Diabetes and Associated Cardiovascular Risk Factors in 

Blacks and Whites: The Chicago Heart Association Detection Project in Industry. 

Unpublished. 
Drury, T. National Diabetes Data Group. Unpublished data from the National 

Health Interview Surveys, NCHS. 
See Harris, Diabetes in America (in press). 
See Harris, Diabetes in America (in press). 
California Department of Health Services... 



225 



Table 2.3 

PERCENT (AND STANDARD ERROR) OF ADULTS AGES 20 to 74 YEARS WITH 

UNDIAGNOSED DIABETES AND IMPAIRED GLUCOSE TOLERANCE, 

UNITED STATES 1976-80 









Percent c 


»f Population (and Standard Error) 




Age (Years) 


20-74 


2C 


)-44 


45-54 


( 


55-64 


6! 


>-74 








Undiagnosed Diabetes'' 


t 










All races 






















Both sexes 


3.2 


(.35) 


.9 


(.31) 


4.2 


(.81) 


6.2 


(1.03) 


8.4 


(.84) 


Male 


2.8 


(.41) 


.8 


(.39) 


3.6 


(1.28) 


4.0 


(1.03) 


9.5 


(1.42) 


Female 


3.6 


(.42) 


1.0 


(.38) 


4.7 


(1.14) 


8.1 


(1.68) 


7,6 


(.89) 


vmite 






















Both sexes 


3.0 


(.38) 


.7 


(.31) 


4.0 


(.90) 


5.9 


(1.24) 


8.0 


(.85) 


Male 


2.5 


(.36) 


.5 


(.27) 


3.2 


(1.25) 


3.8 


(1.00) 


9.0 


(1.38) 


Female 


3.4 


(.52) 


.8 


(.40) 


4.6 


(1.25) 


7.9 


(2.08) 


7.3 


(.95) 


Black 






















Both sexes 


4.4 


(.91) 


,9 


(.68) 


7.2 


(3.05) 


7.7 


(3.75) 


12.3 


(3.94) 


Male 


4.0 


(1.72) 


1.0 


(.98) 


7.5 


(6.40) 


5.2 


(3.94) 


12.2 


(7.23) 


Female 


4.6 


(1.35) 


.9 


(.91) 


7.0 


(3.70) 


9.1 


(5.92) 


12.3 


(4.50) 






Impaired Glucose 


Tolerance* 










All races 






















Both sexes 


4.6 


(0.4) 


2.1 


(0.4) 


7.0 


(1.0) 


7.4 


(0.9) 


9.2 


(0.8) 


Male 


4.6 


(0.6) 


1.2 


(0.4) 


7.3 


(1.7) 


9.8 


(1.5) 


8.9 


(1.5) 


Female 


4.7 


(0.7) 


2.8 


(0.7) 


6.7 


(1.5) 


5.2 


(1.3) 


9.4 


(1.2) 


White 






















Both sexes 


4.6 


(0.4) 


2.0 


(0.4) 


6.3 


(1.1) 


7.7 


(1.0) 


9.5 


(0.9) 


Male 


4.4 


(0.6) 


1.0 


(0.3) 


6.4 


(1.8) 


10.1 


(1.5) 


9.0 


(1.5) 


Female 


4.7 


(0.7) 


2.8 


(0.7) 


6.2 


(1.1) 


5.5 


(1.5) 


9.9 


(1.2) 


Black 






















Both sexes 


3.8 


(0.8) 


1.2 


(0.8) 


10.7 


(3.3) 


4.5 


(2.3) 


3.4 


(2.3) 


Male 


5.9 


(1.2) 


1.4 


(1.3) 


18.8 


(4.0) 


7.0 


(4.9) 


5.4 


(4.1) 


Female 


2.3 


(1.3) 


1.1 


(1.1) 


5.1 


(4.9) 


3.1 


(2.2) 


1.9 


(2.3) 



*Based on results of 75-gram oral glucose tolerance tests (OGTTs) administered in the morninf 
after an overnight 10- to 16-hour fast, in persons who reported that they had no medical 
history of diabetes. OGTTs were classified using National Diabetes Data Group criteria. 
Adjusted to the 1978 United States population. 

Source: Hadden, WC, and MI Harris. Prevalence of diagnosed diabetes, undiagnosed diabetes 
and IGT in adults 20-74 years of age. National Center for Health Statistics Series 
11, in preparation. 



226 



Table 2.4 
PREVALENCE OF DIABETES IN YOUNG UNITED STATES BLACKS 



lefer- 

snce 


Location 


a 


United States 


b 


United States 


c 


United States 


d 


Atlanta, Ga. 


e 


Harlem, N.Y. 


f 


New Orleans, 
La. 


g 


Erie County, 
N.Y. 


h 


Michigan 


1 


St. Louis, Mo 


i 


Pittsburgh, 
Pa. 



Year 



Age 
(Years) 



Prevalence* 
(Percent) 



Comments 



1965 



1973 



1967 



1968 



1973 



1975 



<15 



<17 



1979-81 <25 
1928 <20 

1942 10-19 



0.13 

0.15 
(Rare) 



<16 



<16 



0.03 



School 0.05 

children 

<15 



Those less than age 15 made up a greater X of white dlabe 
than black diabetics 

Very small sample; little difference between 
blacks and whites 

Small sample; little difference between blacks and whites 



Black diabetics In this age group were O.SZ of all dlabet 
whites, 1.9Z 

Preponderance of white diabetic juvenile diabetes patient 
relative to blacks 

Nonwhlte prevalence was about half of white prevalence 



Review of school records; nonwhlte prevalence was about h 
of white prevalence 

White diabetics made up greater X of hospital admissions < 
children 



1976 5-17 Nonwhlte males. White rate was 20Z higher than nonwhlte rate 

0.14; nonwhlte 
females, 0.15 



'Diagnostic criteria: Previous medical history of diabetes or not stated. 



' REFERENCES 

a 
b 



Vital a 



National Center for Health Statistics. Characteristics of Persons with Diabetes, United States, 1964-65. 

Health Statistics, Series 10, Number 40, October, 1967. 
National Center for Health Statistics. Prevalence of Chronic Conditions of the Genitourinary, Nervous, Endocrine, 

Metabolic, Blood and Blood-Formlng Systems, and of Other Selected Chronic Conditions. Vital and Health Staclstl 

Series 10, Number 109, March, 1977. 

c. Drury, T. Division of Epidemiology and Health Promotion, National Center for Health Statistics. Data from the 19 

National Health Interview Surveys. 

d. Bowcock, HM. Diabetes mellltus In the Negro race: A study of one hundred consecutive cases. Southern Med J 

21:994-98, 1928. 

e. Altschul, A, and A Nathan. Diabetes mellltus In Harlem Hospital outpatient department In New York. 

JAMA 119:248-52, 1942. 

f. Rosenbaum, P. Juvenile diabetes at Charity Hospital. J La State Med Soc 199:389, 1967. 

g. Sultz, MA, ER Schleslnger, and WE Mosher. The Erie County survey of long-term childhood Illness: II. Incidence 

and prevalence. AJPH 58:491-98, 1978. 
h. Gorwltz, K, GG Howen, and T Thompson. Prevalence of diabetes In Michigan school-age children. Diabetes 25:122-27 

1976. 
1. MacDonald MJ. Lower frequency of diabetes among hospital Negro than white children: Theoretical Implications. ^ 

Genet Med Gemellol 24:119-26, 1975. 
j. LaPorte, R. Unpublished data from the Allegheny County Insulin-dependent Diabetes Registry. 



227 



Table 2.5 

AGE-ADJUSTED* DEATH RATES FROM DIABETES AS THE UNDERLYING CAUSE OF DEATH PER 100,000 
POPULATION, AND FEMALE/MALE RATIOS, BY RACE AND SEX, UNITED STATES, 1938-1980 



Year 



Males 



White 



Females 



Female/Male Ratio 



Males 



Black 



Females Female /Male Ratio 



1938 
1940 
1945 



18.9 
20.6 
18.3 



31.1 
32.8 
29.1 



1.6 
1.6 
1.6 



13.2 


29.0 


15.0 


32.2 


13.7 


27.9 



2.2 
2.1 
2.0 



Rates before 1949 are not comparable to those after 1949 because of changes in the 
classification of causes of death in that year. 

1.5 11.5 22.7 2.0 

1.3 11.7 22.7 1.9 

1.2 16.2 27.3 1.7 

1.1 17.7 28.0 1.6 

1.0 21.2 30.9 1.5 

1.0 18.7 26.0 1.4 

0.9 17.7 22.1 1.2 



1950 


11.3 


16.4 


1955 


11.0 


14.3 


1960 


11.6 


13.7 


1965 


11.9 


12.8 


1970 


12.7 


12.8 


1975 


10.7 


10.2 


1980 


9.5 


8.7 



*Age-adjusted to the total population of the United States in 1940. 

Source: Division of Vital Statistics, National Center for Health Statistics. 



228 



Table 2.6 

NUMBER OF DEATHS AND DEATH RATE FROM DIABETES AS THE UNDERLYING 
CAUSE OF DEATH BY AGE, SEX, AND RACE, UNITED STATES, 1980 



Age at Death 














(Years) 


Number of Deaths 


Death Rate* 


Number of Deaths 


Death Rate* 




White 


Males 




Black 


Males 


;3 


All ages 


12,125 




13.23 


2,010 




16.05 


Under 25 


65 




0.17 


26 




0.39 


25-34 


260 




1.70 


55 




2.81 


35-44 


373 




3.49 


120 




9.75 


45-54 


853 




8.93 


216 




21.18 


55-64 


2,217 




24.58 


489 




57.45 


65-74 


3,682 




61.06 


577 




102.10 


75-84 


3,314 




128.90 


415 




182.80 


85+ 


1,361 




221.70 


112 




211.30 




White ] 


Females 




Black ] 


Females 


;'^ 


All ages 


16,734 




17.31 


3,534 




25.30 


Under 25 


68 




0.19 


20 




0.29 c 


25-34 


192 




1.25 


58 




2.58 i/^ 


35-44 


283 




2.60 


107 




7.23 


45-54 


741 




7.37 


328 




26.24 


55-64 


2,231 




21.87 


739 




70.00 .1: 


65-74 


4,583 




58.23 


1,143 




147.70 


75-84 


5,507 




124.60 


806 


• 


224.50 


85+ 


3,138 




219.40 


333 




314.20 



*Death rate: number of underlying cause deaths in each age/race/sex group divided 
by the number of 100,000 living persons in the group. 

Source: Division of Vital Statistics, National Center for Health Statistics. 



229 



Chapter 3 
DIABETES IN NATIVE AMERICANS 



Until the 1930's, diabetes mellitus occurred infrequently among Native 
Americans. In the last 50 years, diabetes has increased dramatically in most 
tribes. As table 1.1 indicates. Native Americans are more than 10 times as 
likely as whites to incur noninsulin-dependent diabetes. One tribe, the Pima 
Indians, has the highest rate of diabetes in the world. About 50 percent of 
Pimas 35 years of age and older develop the disease. The increase in diabetes 
in Native Americans can only be termed an epidemic. 

With the exception of some Athabascan tribes and Eskimos, diabetes also 
has become a major cause of morbidity and mortality in Native Americans. 
Diabetes-related mortality (age-adjusted) in Native Americans is 2.1 times 
higher than the rate for all races in the U.S., according to a 1978 Govern- 
ment report. Table 3.1 shows that in Indians and Alaska natives, the diabetes 
mortality ratio, compared with that for all races, rose from 1.3 in 1955 to 2.6 
in 1978. In the same period, the ratio to races other than white rose from 
parity to 1.4. 

The serious complications of diabetes are increasing in frequency among 
Native Americans. Of major concern are high rates of renal failure, amputa- 
tions, and blindness. In its most recent report, the National Diabetes 
Advisory Board noted that approximately 40 percent of all Indians receiving 
dialysis or transplantation services in 1983 had diabetes, compared with ap- 
proximately 25 percent of the general population. The cost of diabetes- 
related kidney disease in one Indian Health Service (IHS) administrative 
region alone in 1984 was $2.6 million. 

Prevalence and Incidence 

Early reports by physicians working with Native Americans indicated that 
diabetes was rare. Although considerable differences were found among tribes, 
the overall frequency of the disease as late as the 1930 's was comparable to 
that of the rest of the population. A study of photographs of Native Americans 
made late in the 19th century reveals that they were typically lean. Along 
with an increase in diabetes, many tribes have shown a dramatic increase in 
the prevalence of obesity in recent years. The increase is not restricted to 
any age group and appears to be related to the consumption of foods higher in 
calories and lower in fiber than their former diets contained, coupled with 
a decrease in physical activity. 

Among the more than 432 Native American Tribes in North America, at 
least 391 live in the United States. The considerable homogeneity of race 
among them points to a common Mongoloid origin. The Eskimo, Aleut, and 
Na-Dene language group of Indians, which includes Navajos and Apaches (all of 
whom have more recently come to this continent), are genetically distinct 
from other Native Americans. 



230 



Table 3.2 summarizes most of the studies of diabetes prevalence in North 
American Indians and Eskimos published since 1940. Since both methods and 
criteria vary from study to study, even within tribes, it is difficult to 
draw inferences from a comparison of the data. It is obvious, however, that 
in the last 40 to 50 years, the problem of diabetes among Native Americans 
has mushroomed. 

The net effect is dramatically illustrated in the two most recent studies 
of the Pima Indians, conducted from 1965 to 1969 and from 1965 to 1979, both 
of which were sponsored by the National Institutes of Health. The two studies 
found almost identical rates of prevalence — overall percentages of 49.8 and 
49.5. The increase was apparent despite the development of more stringent 
criteria for diabetes classification in the later period. An NIH population 
study of Pima Indians showed a 42-percent increase in a 10-year period in 
diabetes prevalence in both sexes and for all age groups (except the youngest) 
(figure 3.1 and table 3.3). 

The prevalence rate found in Athabascans in Alaska, about 3 percent, is 
closer to the rate in genetically unrelated Eskimos than to the rate in the 
three Athabascan tribes in the Southwest. On the other hand, the Pima Indians 
show a rate of prevalence (about 50 percent) in adults 35 years old and older 
that is comparable to the rate among members of the related Papago Tribe , who 
like the Pima live on arid desert reservations. The rate is several times as 
high as the rates in the unrelated San Carlos Apaches (25 percent), Whiteriver 
Apaches (11 percent), and Navajos (13 percent). 

In addition to the Pima, Papago, and San Carlos Apaches, other tribes 
also show rates of prevalence of diabetes of 20 percent or more in adults: 
the Upland Yuman, Maricopa, and Cocopah of Arizona; the Zuni of New Mexico; 
the Paiute of Nevada; the Seminole of Florida; the Cherokee of North Carolina; 
the Pawnee of Oklahoma; the Alabama-Coushatta of Texas; and the Seneca of New 
York. 

Incidence rates in Pima and Choctaw Indians of both full and more than 
half heritage are compared in table 3.4. Although neither the periods of 
study nor the methods used were comparable, these differences could not 
account for the large and consistent differences in the findings. At all 
ages except in the oldest males, the incidence was higher in the Pima than in 
the full-heritage Choctaw. The Choctaw also showed higher rates, except in 
the oldest group, than Choctaw of less than full heritage. Further evidence 
of the relation between the degree of Indian heritage and diabetes is provided 
in table 3.5, which compares the Choctaw of Oklahoma, the Cherokee of North 
Carolina, and the "Three Affiliated Tribes" of North Dakota. 

Obesity, Family History, and Genetic Factors 

The 42-percent increase in the prevalence of diabetes in the Pima popu- 
lation between 1967 and 1977 was paralleled by an increase in obesity, which 
as table 3.6 indicates was highest in those younger than 35. A longitudinal 
study, illustrated in figure 3.2, demonstrated that the increase in risk of 
future diabetes correlated with the age of onset of obesity. 



231 



Investigators have concluded that NIDDM is familial. The data illustra- 
ted in figure 3.3 show the 8-year cumulative probability of the development 
of diabetes in Pimas , at least one of whose parents is diabetic. Figures 3.4 
and 3.5 show that the effects of obesity and family history of diabetes are 
additive. A recent study has found that 58 percent of 15- to 19-year-old 
children of Pimas with diabetes were 140 percent or more over "desirable" 
weight; among the children of prediabetics and nondiabetics , the rates were 
25 and 17 percent, respectively. 

Genetic components have been found for NIDDM in the Pima Indians. At 
all ages, the presence of the HLA-A2 leukocyte antigen is more frequent in 
the Pima with diabetes than in the Pima without diabetes. At age 55, HLA-A2 
is present in 59 percent of those with diabetes and 39 percent of those 
without the disease. It has also been found that 1.5 kb DNA in the 5' flank- 
ing region of the insulin gene is associated (p = 0.01) with NIDDM in un- 
related Pimas as well as in American blacks and whites. 

Complications 

The complications of diabetes are widespread among Native Americans, 
particularly diabetes-related kidney disease, amputation, and blindness. 
Diabetes increases the otherwise low rate of coronary artery disease in 
Indians of the Southwest. The 6-year incidence of retinopathy and heavy pro- 
teinuria (an index of nephropathy) among Pima Indians is shown in figure 3.6. 
People who have hyperglycemia exhibit these complications much more frequently 
than do people with euglycemia. About half of the deaths from vascular 
causes in the Pima are attributed to diabetic nephropathy. Native Americans 
as a whole seem to develop end-stage renal disease more frequently than other 
groups in our population, and the number of Native Americans who require 
renal dialysis has grown rapidly. 

Prevent ion/ Treatment 

Among many Indian tribes of North America, diabetes has attained epidemic 
proportions. Diabetic complications are major causes of morbidity and mortal- 
ity in most Native American populations. The basic disease and its deleteri- 
ous long-term effects are similar in all ethnic groups, and factors involved 
in the causes and complications of diabetes and the principles of management 
appear to be generally applicable to all races. 

In recognition of the severity of the problem, the Indian Health Service 
developed the Model Diabetes Care Program, which has been established at 
several existing IHS service units. IHS projects are located in five States: 
Oklahoma, North Dakota, Arizona, Nebraska, and New Mexico. The projects in 
these five States account for more than 8,000 diabetes-related outpatient 
visits each year. Considerable progress has been made at these five sites in 
delivering high-quality, culturally acceptable diabetes care. 

The model sites now serve only about 10 percent of the IHS population. 
Additional resources approved by Congress in fiscal year 1985 will enable the 
program to be expanded to two additional sites and will provide funds to pur- 
chase laser photocoagulation equipment to treat diabetic retinopathy. Trans- 
ferring effective treatment strategies from the model sites to other service 



232 



units has only begun. Extensive innovative efforts are needed to interrupt 
the increasing prevalence of diabetes among North American Indians and reduce 
morbidity and mortality. 



233 



REFERENCES 



1. Bartha GW, Burch TA, and Bennett TH. Hyperglycemia in Washoe and 
Northern Paiute Indians. Diabetes 1973, 22:58-62 

2. Bennett PH. Panel on diabetes. (Scientific Publication No. 257) In: 
Epidemiologic studies and clinical trials in chronic diseases. Pan 
American Health Organization, 1972, Washington, D.C., pp. 31-38 

3. Bennett PH, and Knowler WC. Increasing prevalence of diabetes in the 
Pima (American) Indians over a ten-year period. (International Con- 
gress Series No. 500.) In: Diabetes 1979, Excerpta Medica Foundation, 
1980, Amsterdam, pp. 507-11 

4. Bennett PH, and Miller M. Vascular complications of diabetes in American 
Indians, Japanese and Causasians. In: Baba S, Goto Y, and Fyui I, eds . 
Diabetes mellitus in Asia. Excerpta Medica Foundation, 1976, Amsterdam, 
pp. 202-07 

5. Bennett PH, Rushforth NB, Miller M, and LeCompte PM. Epidemiologic 
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32:333-76 

6. Doeblin TD, Evans K, Ingall GB, Dowling K, Chilcote ME, Elsea W, and 
Bannerman RM. Diabetes and hyperglycemia in Seneca Indians. Hum 
Hered 1969; 19:613-27 

7. Hamraan RF, Bennett PH, and Miller M. Incidence of diabetes among the Pima 
Indians. Adv Metab Disord 1978; 9:49-63 

8. Henry RE, Burch TA, Bennett PH, Miller M. Diabetes in the Cocopah In- 
dians. Diabetes 1969; 18:33-37 

9. Johnson JE, and McNutt CW. Diabetes mellitus in an American Indian popula- 
tion isolate. Tex Rep Biol Med 1964; 22:110-25 

10. Justice JW. Carbohydrate intolerance among the Gila River tribes of 
Arizona. (Abstract.) In: Proceedings of the Second Joint Meeting of 
CCA and Commissioned Officers Association. USPHA, 1967, Atlanta, Georgia, 
p. 7 

11. Justice JW. Estimated prevalence of diabetes in American Indians and 
Alaskan Natives in three IHS areas. Personal written communication, 
February 11, 1983 

12. Knowler WC, Pettitt DJ, Savage PJ, and Bennett PH. Diabetes incidence 
in Pima Indians: Contributions of obesity and parental diabetes. Am 
J Epidemiol 1981; 113:144-56 

13. Mouratoff GJ, and Scott EM. Diabetes mellitus in Eskimos after a decade. 
JAMA 1973; 226:1345-46 



I 



234 



14. Mouratoff GJ , Carroll NV , and Scott EM. Diabetes mellitus in Athabascan 
Indians in Alaska. Diabetes 1969; 18:29-32 

15. Pettitt DJ, Baird RH, Aleck MS, Bennett PH, and Knowler WD. Excessive 
obesity in offspring of Pima Indian women with diabetes during pregnancy. 
N Engl J Med 1983; 308:242-45 

16. Rotwein PS, Chirgwin J, Province M, Knowler WC, Pettitt DJ , Cordell B, 
Goodman HM, and Permutt MA. Polymorphism in the 5' flanking region of the 
human insulin gene: A genetic marker for noninsulin-dependent diabetes. 

N Engl J Med 1983; 308:65-71 

17. Sievers ML. Disease patterns among Southwestern Indians. Public Health 
Rep 1966; 81:1075-1083 

18. Sievers ML, and Fisher JR. Diseases of North American Indians. In: Roths- 
child HR, ed. Biocultural aspects of disease. New York: Academic Press, 
1981; pp. 191-252. 

19. Sievers ML, and Fisher JR. Diabetes in North American Indians, Chapter XI, 
Diabetes Databook, NIADDK/NIH, in press 

20. Smith CG. Culture and diabetes among the Upland Yuma Indians. Unpublished 
doctorate thesis. University of Utah, 1970 

21. Stein JH, West KM, Robert JM, Tirador DF, and McDonald GW. The high pre- 
valence of abnormal glucose tolerance in the Cherokee Indians of North 
Carolina. Arch Intern Med 1965; 116:842-45 

22. Swanton JR. The Indian tribes of North America. Washington, D.C.: 
Smithsonian Inst Press, 1952 

23. U.S. Department of Health, Education, and Welfare. Indian health trends 
and services. Washington, D.C.: Superintendent of Documents, U.S. Govern- 
ment Printing Office, 1978 

24. West KM. Diabetes in American Indians and other native populations of the 
New World. Diabetes 1974; 23:841-55 

25. Westfall DN, and Rosenbloom AL. Diabetes mellitus among the Florida 
Seminoles. HSMHA Health Rep 1971; 86:1037-41 

26. White WD. Diabetes in the Oklahoma Indian. (Abstract.) In: Proceed- 
ings of the First Joint Meeting of COA and Commissioned Officers Associa- 
tion. USPHS, 1966, Baltimore, Maryland, p. 21 

27. Williams RC, Knowler WC, Butler WJ , Pettitt DJ , Lisse J, Bennett PH, 
Mann DL, Johnson AH, and Terasaki PI. HLA-A2 and type II diabetes in 
Pima Indians: An association and decrease in allele frequency with 
age. Diabetologia 1981; 21:460-64 



235 



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243 



Table 3.3 

INCREASED PREVALENCE OF DIABETES* IN PIMA INDIANS AGES 5 YEARS 

AND OLDER, 1967-77 



Age-adjusted Rate (±SE)/100 Persons* * 
Sex 1967 1977 Percent Change 



Males 20.0(1.4) 31.6(1.9) +58 

Females 27.6(1.6) 36.3(1.8) +38 

Both 24.0(1.1) 34.1(1.3) +42 



♦Criterion for diabetes = 2-hour post 75-gm glucose of >^ 200 mg/dl 
**The 1970 United States population used as standard population 

SOURCE: Bennett, PH, and WC Knowler. Increasing prevalence of diabetes 
in the Pima (American) Indians over a ten-year period. (Inter- 
national Congress Series No. 500.) In: Diabetes 1979, Excerpta 
Medica Foundation, 1980, Amsterdam. 



244 



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Table 3.5 


















REPORTED 


PREVALENCE RATES OF DIABETES MKLLITtrS AMONG 


NORTH 


AMERICAN 


INDIANS 


, BY TRIBE 


» 










ACE GROUP, YEARS OF STUDY, AND 


PUTATIVE QUANTUM 


INDIAN HERITAGE 


























Dlabacas 


Mellitua 


i 














Study Population 


(Par cent 


(and Number) of { 




Trlba and 


Taara of Study Nathod and 


Aga 

Group 


Indian 
Quantua 


(Numbar of Parsona) 


Peraona) 




• 


Kafar- 








•ne« 


I«caclati 


Study 


Dlagnoatle Crltaria* 


(Taara) 


(Elghtha) 


Malaa 


Faaalaa 


Both 


Halaa 


Feaales 


Both 


a 


Choctaw 


19S6- 


Chart ravlaw; plaa«a 


All 


8/8 


831 


1162 


1993 


5.7(47) 


5.1(59) 


5.3(106) 




(OUahoM) 


1961 


flueoaa >160 ag/dl 
2 hour* pioat 75-sm 




<8/8.>l/8 


741 


841 


1582 


2.3(17) 


1.4(12) 


1.8(29) 








flueoaa 


>30 


8/8 


433 


587 


1020 


10.6(46) 


10.1(59) 


10.3(105) 












<8/8,>l/8 


218 


287 


505 


7.8(17) 


4.2(12) 


5.7(29) 


b 


Charokaa 


1965 


Study of 1/4 to 1/2 


>35 


8/8 


_ 


_ 


154 


• 


• 


29.2(45) 




(North 




of population; plaaaa 




<8/8,>6/« 


- 


•> 


105 


- 


- 


36.2(38) 




Carolina) 




Slucoaa >160 ng/dl 




<6/8,>6/8 


- 


- 


43 


- 


- 


41.9(18) 








2 heura piaat 7S-gB 




<4/8,>2/8 


- 


- 


34 


- 


- 


8.8(3) 








glueoaa 




>2/8~ 


- 


- 


30 


- 


- 


20.0(6) 












<4/8 


- 


- 


302 


- 


- 


33.4(101) 












>4/8 


- 


- 


64 


- 


- 


14.1(9) 












ITnknoim 


- 


- 


82 


- 


- 


24.4(20) 


e 


Mandan, 


1978 


Chart ravlow of por- 


O* 


8/8 


_ 


« 


1145 


« 


• 


0.7(8) 




Arlkara, and 




•ona with a pravloua 




<8/8,>4/8 


- 


- 


885 


- 


- 


0.7(6) 




Rldataa — 




dlafnoala of dlabataa 




<4/8 


- 


- 


812 


- 


- 


0.7(6) 




"Thrao 








isna 


- 


- 


- 


- 


- 


- 



Plaa and 


1965- 


Papage 


1982 


(Arlaona) 





Conplate population 
atudlad; plaama glu- 
eoaa >200 ag/dl 2 
houra poat 7S-gB 
glueoaa 



>35 



>35 



8/8 
<8/8,>4/8 
<4/8 
Nona 

8/8 
<8/8,>4/8 
<4/8 
N»na 



537 

194 

146 

97 



22.3(120) 

14.9(29) 

4.1(6) 

4.1(4) 



645 

3 

7 

13 



662 

13 

5 

3 



1307 46.7(301) 57.7(382) 52.3(683) 

16 33.3(1) 46.2(6) 43.8(7) 

12 28.6(2) 60.0(3) 41.7(5) 

16 7.7(1) (0) 6.3(1) 



*Heat but net all aubjaeta ware atudlad by thaae aathoda and criteria. 
REFERENCES 



d. 



Dreveta, CC. Dlabataa iMlllcua In Choctaw Indiana. J Okla State Med Aaaoe 58:322-29, 1965. 

Stein, jn, KM Ueat, JM Robey, DF Tlrador, and GW McDonald. The high prevalence of abnomal glucoae tolerance In che 

Cherokee Indiana of North Carolina. Arch Intern Med 116:842-45, 1965. 
Broaaaau, JD, RC Ealkaaa, AC Crawford, and TA Aba. niabetea anong the Three Affiliated Trlbea: Correlation with 

degree of Indian Inheritance. Aa J Public Health 69:1277-78, 1979. 
Knowlar, WC. Peraonal eoHBunleatlon, 1983. 



246 



Table 3.6 

CHANGES IN MEAN BODY WEIGHT, PERCENT DESIRABLE WEIGHT (PDW), AND 
BODY MASS INDEX (BMI)* IN PIMA INDIANS AGE 15 YEARS AND OLDER 
DURING THE 10-YEAR PERIOD BETWEEN 1967 AND 1977 



Sex and Age (Years) 



Weight (kg) 



P-Value 



PDW 



BMI* 



P-Value 



Males 
15-24 
25-34 
35-44 
45-54 
55-64 
>65 

Females 
15-24 
25-34 
35-44 
45-54 
55-64 
>65 



9.24 


<.001 


10.57 


2.57 


<.001 


8.58 


<.01 


10.89 


2.69 


<.01 


3.41 


NS 


4.84 


1.13 


NS 


3.33 


NS 


2.57 


0.62 


NS 


1.84 


NS 


0.81 


0.25 


NS 


0.87 


NS 


1.37 


0.32 


NS 


6.56 


<.001 


10.57 


2.17 


<.001 


5.62 


<.01 


9.32 


1.91 


<.01 


0.93 


NS 


-0.09 


-0.04 


NS 


4.26. 


<.05 


4.10 


0.71 


NS 


5.37 


<.05 


8.61 


1.78 


<.05 


■1.03 


NS 


-3.63 


-0.83 


NS 



*BMI » (body weight in kg) /(height In m)2 

SOURCE: Bennett, PH, and WC Knowler. Increasing prevalence of diabetes In the 

Pima (American) Indians over a ten-year period. (International Congress 
Series No. 500.) In: Diabetes 1979, Excerpta Medlca Foundation, 1980, 
Amsterdam. 



247 



Figure 3 . 1 



70 
60 

Sso 

S40 

c 

g 30 

% 
£20 

10 





Males 



1977 




Females 



/A\ 




IO203O4O5O6O66*IO203O4O5O6O65* 



Age (years) 



AGE-SPECIFIC PREVALENCE OF DIABETES IN PIMA INDIANS, 
1967 AND 1977 



Source: Bennett, PH, and WC Knowler. Increasing prevalence of diabetes In 
the Pima (American) Indians over a ten-year period. (International 
Congress Series No. 500). In: Diabetes 1979, Excerpta Medlca 
Foundation, 1980, Amsterdam. 



248 



Figure 3.2 



00 

0) 

u 



60 



40 - 



o 



■ 



»< 



20 



I 


> 








J 


4 




3.0 


§: 


M * ^ 






(-U 


^ 




o 




• 


^ 




c 






^F 


_ 


ll> 




5a 


^^ 




fl 




(D 


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3 


rr 


1.6 




^r _^r J 


! 2 




1.1 


CO 


^^^ ^^^^^^^^ ^^^^^' 


1 




1.0 


rr 






2 4 6 8 








Years in Study 











CUMULATIVE PROBABILITY (CP) OF DEVELOPMENT OF DIABETES IN PIMA 
INDIANS BY BODY MASS INDEX OUARTILE (1-16 . 16-24.242; 2-24.243- 
28.089; 3-29.090-32.526; 4-32.527-52.861) AND YEARS IN STUDY. 
ADJUSTED RELATIVE RISK DEVELOPED FROM MULTIPLE REGRESSION ADJUSTED 
RATES.- 

Source: Hatnman, RF, PH Bennett, and M Miller. Incidence of diabetes among 
the Pima Indians. Adv Metab Disord 9:59, 1978. 



249 



Figure 3.3 



n = 121 



549 



350 



30 



u 



o ^s 



o 
u 
CO 



20 • 



10 * 




Negative Unknown Positive 
Family History 



Adj. Rel. Risk 1.00 



1.39 



1.85 



EIGHT- YEAR COTfULATIVE PROBABILITY (CP) OF DEVELOPMENT OF 
DIABETES IN PIMAS BY FAMILY HISTORY (AT LEAST ONE PARENT 
HAVING DIABETES). ADJUSTED RELATIVE RISK DEVELOPED FROM 
MULTIPLE REGRESSION RATES. 

Source: Hamman, RF, PH Bennett, and M Miller. Incidence of diabetes 
among the Pima Indians. Figure 3. Adv Metab Disord 9:61, 
1978. 



250 



Figure 3.4 





60- 


Obesity Quartile 


a 

Q 


50- 
40- 


12 3 4 


: C.P. of 
(%) 


30- 
20- 






10- 
0- 


-. di c 




Negative Unknown Positive 
Family History 



EIGHT- YEAR CUMULATIVE PROBABILITY (CP) OF PIMAS DEVELOPING DIABETES 
BY BODY MASS INDEX QUARTILE (SEE LEGEND, FIGURE 4) AND FAMILY 
HISTORY (AT LEAST ONE PARENT HAVING DIABETES). 



Source: Hamraan, RF, PH Bennett, and M Miller. Incidence of diabetes 
among the Pima Indians. Adv Metab Disord 9:61, 1978. 



251 



Figure 3.5 



CO 

u 

CO 

o 
n 
u 

0) 

PU 

o 
o 

o 



(0 
0) 
(0 
A 
CJ 

g 



0) 

u 

c 

U 

c 



100 



80 



60 -, 



40 



20 



Parental Diabetes 
• • Both 

•••~— •>• One 
• • Neither 




<20 



—I f— 

20-25 25-30 



T 



T 



30-35 35-40 



— 1 
240 



Body Mass Index (kg/m ) 



AGE-ADJUSTED INCIDENCE OF DIABETES IN PIMA INDIANS AGES 5-44 
YEARS, BY BODY MASS INDEX AND PARENTAL DIABETES STATUS AS 
DETERMINED BY GLUCOSE TOLERANCE TESTING 

Source: Knowler, WC, DJ Pettltt, PJ Savage, and PH Bennett. Diabetes 

incidence In Pima Indians: Contributions of obesity and parental 
diabetes. Am J Epidemiol 113(2): 152, 1981. 



252 



Figure 3.6 



8^ 



O 

c 



50 



40- 



•H 30- 



c 

M 
U 

(d 

>* 
I 

vO 



20- 



10- 



oJ 



Retinopathy 
Proteinuria 



r-25 




^e 



G 
01 

9 

cr 
<u 

> 

•rl 
U 
Cd 

i-l 



I — I — I — I — I — I — r— I — I — I — I 

65 100 160 250 400 600 
80 130 200 300 500 

Initial Two Hour Plasma Glucose (mg/dl) 



INCIDENCE OF RETINOPATHY AND HEAVY PROTEINURIA (URINE PROTEIN/ 
CREATININE RATIO GREATER THAN OR EQUAL TO 1.0) OVER A 6- YEAR 
PERIOD, ACCORDING TO INITIAL TWO-HOUR PLASMA GLUCOSE CONCENTRA- 
TIONS (HISTOGRAM), IN PIMA INDIANS. 



Source: Bennett, PH, WC Knowler, DJ Pettitt, MJ Carraher, and B Vasquez. 
Longitudinal studies of the development of diabetes in the Pima 
Indians. (INSERM Symposium No. 22.) In: Eschwege, E, ed. 
Advances in diabetes epidemiology. Amsterdam: Elsevier Biomedical 
Press, 1982. 



253 



Chapter 4 

DIABETES IN HISPANIC AMERICANS 

According to the 1980 census, approximately 14,6 million persons of 
Hispanic ancestry live in the United States. Clinical observation and a few 
local studies seem to indicate that, like other minority groups in the United 
States, Hispanic Americans suffer from diabetes mellltus to a degree dispro- 
portionate to their representation in the population as a whole. As shown in 
table 1.1, Hispanics are more than three times as likely as whites to develop 
nonlnsulin-dependent diabetes. It is important to note that the largest group 
of Hispanics, Mexican Americans, is also the group in which the severity of 
the problem is best documented. It remains to be determined whether the 
risk is shared at the same degree by the 2 million Puerto Rican Americans and 
800,000 Cuban Americans. 

The National Center for Health Statistics is conducting a study known as 
the Hispanic Health and Nutrition Examination Survey (HHANES) to assess the 
health and nutritional status of Mexican Americans, Puerto Ricans, and Cuban 
Americans in selected regions of the United States. The prevalence of certain 
diseases in persons 6 months to 74 years of age will be estimated and compared 
with normative values of certain health characteristics. The use of health 
services will also be estimated in relation to health status. Data tapes for 
Mexican Americans are now being analyzed; data for Puerto Rican Americans and 
for Cuban Americans will be available in January 1986. 

Several methodological considerations should be clarified prior to a dis- 
cussion of diabetes as it affects Hispanics in the United States. There are 
no data on IDDM rates among Hispanic American children or adolescents, and not 
all studies conducted of diabetes in Hispanics have distinguished between 
NIDDM and IDDM. The failure to distinguish between the two types of diabetes, 
however, does not have a significant effect on the reported prevalence rates 
in adults because the great majority of Hispanics identified as having diabetes 
have NIDDM. 

Another methodological consideration is that few of the studies of 
diabetes in Hispanics have used the new diagnostic criteria of the National 
Diabetes Data Group. Since these criteria have higher standards than 
earlier criteria, some Hispanic Americans who reported histories of diabetes 
have been found not to be diabetic under the new criteria. This discussion 
includes such persons as diabetic only if they report that they are taking 
insulin or oral hypoglycemic agents. 

Prevalence and Mortality 

Data on the prevalence of diabetes among Hispanics are derived primarily 
from studies conducted in Texas and Puerto Rico. The results of an early 
study of the prevalence of diabetes in Mexican Americans in Laredo, Texas, 
are summarized in table 4.1, and the results of the more recent San Antonio 
Heart Study (1979-82) are summarized In table 4.2. The San Antonio study 
compared Mexican Americans living in the "barrio" (poor urban area) with 
those living in the suburbs and in transitional neighborhoods. 



254 



The age-specific prevalence rates in the Laredo study are only about 
half of the corresponding rates in the San Antonio barrio (table 4.2). The 
comparison is made with the San Antonio barrio because the Laredo partici- 
pants were all from a socioeconomic group comparable to the San Antonio 
barrio residents. A possible explanation for the discrepancy between the San 
Antonio and Laredo rates is that only fasting plasma glucose values were 
available from Laredo. Although the NDDG criterion for fasting blood glucose 
(>^ 140 mg/dl) was adhered to in the Laredo study, participants who failed to 
meet this criterion but who might have met the NDDG postglucose load criteria 
had glucQse tolerance tests been performed are not included in this study. 
They are included in the San Antonio study. It has recently been reported 
that in Mexican Americans the sensitivity of the fasting plasma glucose test 
in identifying a diabetic condition is only about 59 percent. When the 
Laredo rates are inflated by dividing them by 0.59, they approximate the 
rates observed in the San Antonio barrio. 

Despite the discrepancy in age-specific rates in the two studies, the 
age-adjusted rates in Laredo (13 percent in men and 14 percent in women) are 
quite similar to the San Antonio barrio rates. The difference is explained 
by the age spans of the two samples, which are 45 to 74 in Laredo and 25 to 
64 in San Antonio. It has been established (see chapter 1) that the prevalence 
of diabetes increases with age. 

The results of the San Antonio Heart Study indicate that NIDDM is more 
than twice as prevalent in men living in the barrio as among men from the 
suburbs. In addition, the prevalence rate is almost four times as high among 
barrio women as among suburban women. HANES II, which used essentially the 
same criteria in a study of the general population from 1978 to 1980, found 
NIDDM in 5.7 percent of the men and 7.4 percent of the women among persons 
from 25 to 74 years old. These rates are similar only to those found among 
Mexican Americans who live in the affluent suburbs. The rate of diabetes 
among Mexican Americans in the barrio is approximately twice as high as in 
non-Hispanic whites. It should be noted that while the prevalence of diabetes 
in barrio women is slightly higher than that in barrio men, the rate is 
higher in Mexican-American men in both the transitional neighborhoods and 
the suburbs . 

The prevalence of NIDDM was also studied in Starr County, Texas, on the 
Mexican border, one of the most impoverished counties in the United States. 
The rate of diabetes in Mexican Americans living in this county, therefore, 
should be comparable to that of the barrio population in San Antonio. To 
facilitate comparison to the San Antonio barrio, table 4.3 shows the age-adjusted 
rates for the population of the county aged 5 to 75+ and the population aged 25 
to 64. The study used the same NDDG criteria that were used in San Antonio for 
diagnosis, but screening criteria were more comparable to those used for the 
Laredo study. Hence, the method for identifying NIDDM in the Starr County 
study was similar to that of the Laredo study, in that both based a diagnosis 
of newly discovered cases primarily on fasting hyperglycemia. Presumably for 
this reason, the proportion of newly discovered cases in Starr County is 
relatively low (20 to 25 percent of the cases) and resembles the 15-percent 
proportion in San Antonio. Because of the underascertainment of newly diagnosed 
cases, the age-specific and age-adjusted (25 to 64) rates in Laredo and Starr 
County are substantially lower than in the San Antonio barrio (table 4.2). 



255 



The prevalence of diabetes in Puerto Rican men living in Puerto Rico has 
also been studied. Tables 4.3, 4.4, and 4.5 summarize the results. Table 4.4 
indicates that the age-adjusted prevalence rate of diabetes in urban men (9 per- 
cent) is considerably higher than the rate in rural men (3.5 percent). Because 
the diagnostic criteria used in the Puerto Rico study are very different from 
those used in the San Antonio study, it is not possible to compare the findings. 
The Puerto Rico study diagnosed diabetes if the participant gave a history of 
diabetes or if a casual whole-blood glucose test was M40 mg/dl — the equivalent 
of a plasma-glucose level of 160 mg/dl. This level is higher than the fasting 
level in the NDDG criteria, which would tend to lower prevalence estimates. 
In addition, the specimens are casual rather than fasting, and the study 
included subjects being treated by diet, which the San Antonio study did not. 
These last two methodological differences should have raised the results of 
the Puerto Rico study in relation to the San Antonio results. The relative 
weights in the Puerto Rico study averaged 1.04 for rural and 1.16 for urban 
men. In San Antonio, the corresponding figures were 1.12 for barrio men and 
1.10 for suburban men. These data suggest that relative leanness might in 
part explain the low rates of diabetes among rural Puerto Ricans, but not 
among the urban dwellers. 

Table 4.5 shows the rates of previously and newly diagnosed cases in rural 
and urban men. Newly diagnosed cases accounted for 42 percent of rural cases 
but only 29 percent of urban cases. 

Table 4.6 shows the prevalence of diabetes by relative weight. In both 
urban and rural Puerto Rican men, the prevalence rates of diabetes rose with 
relative weight, but at any relative weight they were higher in urban men than 
in rural men. The implication is that although obesity is a factor in the dif- 
ference between urban and rural men, other factors must also be involved. 

In the area of diabetes mortality, statistics document the high rate of 
diabetes in Mexican Americans. In Texas, rates of mortality from diabetes by 
county range from 8.9 to 52.0 per 1,000 deaths. The mortality rate for dia- 
betes is highly correlated with the proportion of Mexican Americans in the 
population of the county. In Bexar County, which includes San Antonio, the 
diabetes mortality rates declined among both Hispanics and whites from 1970 
to 1976, but in both men and women the rates were consistently two to four 
times as high among Hispanics as among the white population. 

Rates of mortality from diabetes among Puerto Ricans and Cuban Americans 
have not been reported. 

Risk Factors 

Socioeconomic Status and Acculturation . The association between socio- 
economic status and diabetes found in the San Antonio study suggests that 
socioeconomic status may be related to the occurrence of the disease. This 
conclusion has been questioned, however, because both acculturation and 
genetic background have been shown to vary in Mexican Americans with changing 
socioeconomic status. A study of acculturation in the San Antonio population 
conducted by Hazuda and Haffner used a series of multidimensional scales to 
measure the adoption by Hispanic Americans of non-Hispanic behavior, attitudes. 



256 



and values. Even after adjustments were made for age and socioeconomic 
status, investigators found that the prevalence of diabetes declined with 
increasing acculturation. Further adjustment for obesity suggested that 
acculturation could be related to changing patterns of obesity in women, but 
was largely independent of obesity in men. At the same time, even after 
adjustment for socioeconomic status, the study found that obesity was inversely 
related to acculturation in both sexes. It thus appears that acculturation 
may be an important factor independent of socioeconomic status in the prevalence 
of diabetes in Mexican Americans, either through its effects on obesity in 
women or by other mediating pathways in men. 

Genetic Factors . It is possible that some of the inconsistencies found 
in the relation between socioeconomic status and diabetes in Hispanic Americans 
may be associated with genetic admixture. As chapter 3 points out. Native 
Americans have a marked proclivity for diabetes. It could well be that the 
rates of NIDDM in Mexican Americans are primarily attributable to their 
Native American ancestry. According to this theory, the higher rates of 
NIDDM in low-income, barrio Mexican Americans compared with affluent suburban 
Mexican Americans (table 4.2) could be the result of the higher percentage of 
Native American ancestry in the former compared with the latter. 

Socioeconomic status and acculturation do not appear to have a direct 
effect on NIDDM prevalence. Rather, they are proxy variables for various 
health habits that presumably have a more direct Influence on the development 
of diabetes. 

Obesity and Fat Patterning 

Among the health habits that may affect diabetes, diet and exercise would 
appear to be the most promising candidates. However, apart from caloric 
excess, which leads to obesity, there is little definitive information on the 
role of diet and exercise in the development of diabetes in Mexican Americans. 

Obesity is well known to be a risk factor for NIDDM. The San Antonio 
Heart Study also assessed the relation between diabetes and the degree of 
adiposity. Although the Mexican Americans in the San Antonio barrio exhibited 
a higher degree of obesity than either the more affluent Mexican Americans or 
the whites, table 4.7 makes it clear that obesity cannot be the only explana- 
tion. When lean, average, or obese Mexican Americans are compared with 
whites matched in adiposity, the Mexican Americans still exhibit rates of 
NIDDM prevalence that are 2 to 3.5 times as high. 

In addition to overall adiposity, distribution of body fat may be a 
determinant of various metabolic disorders. Although few studies have been 
made of fat patterning in Mexican Americans and whites, there is some evidence 
based on subscapular and tricep skinfolds that Mexican Americans have a more 
central distribution of body fat compared with non-Hispanic whites. 

Recently, interest in fat patterning has shifted to lower versus upper 
body adiposity, with the latter type considered to have a higher propensity to 
metabolic derangement. Unfortunately, there do not appear to be any data on 
ethnic differences between Mexican Americans and non-Hispanic whites concern- 



257 



ing lower versus upper body adiposity, although such data are currently being 
collected. Differences in lower versus upper body adiposity between people 
with diabetes and those without the disease, however, have been reported for 
Mexican Americans from Starr County, Texas. In this study, Mexican-American 
diabetics had relatively more upper body fat and less lower body fat than 
Mexican-American nondiabetics . 

Complications 

Data are quite limited on the incidence of complications from diabetes 
in Mexican Americans. Evidence has recently been presented, however, suggest- 
ing that NIDDM in Mexican Americans is metabolically more severe than in non- 
Hispanic whites. This finding is illustrated in table 4.8. The San Antonio 
Heart Study tested diabetic whites and Mexican Americans for plasma-glucose 
concentration 2 hours after an oral glucose load. Investigators found that 
twice as many Mexican Americans as non-Hispanic whites showed concentration 
higher than 300 mg/dl. Table 4.9 may clarify the question whether the relative 
impairment in Mexican Americans is due to insufficient access to medical care, 
to a lower quality of medical care, or to some other factor. 

The San Antonio study encountered new diagnoses of diabetes in roughly 
the same percentage in the Hispanic as in the general population (61.2 per- 
cent of whites and 58.3 of Hispanics). This finding suggests that Mexican 
Americans are not less likely than whites to have their diabetes come to 
medical attention. Also, the percentage of diabetics under treatment with 
oral agents or insulin was higher in Mexican Americans than in whites. Nei- 
ther finding supports the conjecture that inadequate treatment is responsible 
for deficiencies of metabolic control in Mexican Americans, although poor 
compliance with therapeutic regimens is possible among the Mexican-American 
patients. The findings also could indicate that the greater hyperglycemia in 
Mexican Americans is a real phenomenon and has led to more aggressive treatment 
by physicians. 

Table 4.9 also indicates that Mexican Americans with diabetes tend to be 
diagnosed at an earlier age than whites (see chapters 1 and 2 for parallels 
in black Americans). Consequently, Mexican Americans at any age would exhibit 
a longer history of the disease. This fact may explain their higher rate of 
hyperglycemia. It also raises the question whether they suffer disproportion- 
ately from the complications of diabetes and the mortality associated with 
these complications. Unfortunately, there is practically no information avail- 
able on the incidence of complications of diabetes among Mexican Americans. 

Prevention 

It is clear that noninsulin-dependent diabetes is a major health burden 
contributing to excess morbidity and mortality in the Mexican-American 
population. There is still inadequate data, however, to say with certainty 
whether this increased diabetes-related health burden extends to the other 
Hispanic subgroups in the United States. Increased support of public health 
programs to educate the Mexican-American population about diabetes and to 
contribute to its prevention are certainly warranted. Also, efforts to 



258 



identify undiagnosed cases and to bring them under medical surveillance are 
needed, because, as with other segments of the U.S. population, approximately 
half of the Mexican Americans with diabetes are unaware of their disease. 

Finally, expanded treatment facilities are needed. Public health educa- 
tion programs aimed at prevention and health care services aimed at treatment of 
established cases need to be tailored to the cultural orientation of the 
Mexican-American population. Health education materials should be available 
in Spanish, the preferred language of many Mexican Americans, and the content 
of these materials should be sensitive to cultural nuances that can heavily 
influence whether the information and guidelines are likely to be acceptable 
to the population they are designed to serve. Ongoing research on the relation- 
ship between cultural orientation and health habits and attitudes should assist 
in the design of culturally acceptable educational materials. 

It is important to establish whether the predisposition to diabetes found 
among Mexican Americans is shared by other Hispanic subgroups. This question 
should be answered in the case of Puerto Rican and Cuban Americans by the 
soon-to-be-completed Hispanic HANES study. Studies of Hispanic children and 
adolescents are needed to assess the frequency of insulin-dependent diabetes 
in this population. Currently, data on this important topic are completely 
lacking. 

Further studies are needed on the customary diets of various Hispanic 
subgroups and the possible relationship of these diets to obesity, fat pattern- 
ing, and diabetes. There are almost no data available on micro- and macro- 
vascular complication rates in Hispanic diabetics, although such data are 
currently being gathered. These data are particularly important because in 
the San Antonio Heart Study, Mexican-American diabetics had a longer disease 
duration and greater severity of hyperglycemia, both of which increase the 
risk of diabetic complications. These observations need to be confirmed in 
other Hispanic populations. Finally, health services research and research 
on compliance with medical regimens are needed in Hispanic populations to 
identify deficiencies in access to or quality of medical care and to suggest 
culturally valid strategies for correcting whatever deficiencies are identified. 



259 



SOURCES 



National Diabetes Data Group. Classification and diagnosis of diabetes mellitus 
and other categories of glucose tolerance. Diabetes 28:1039-57, 1979. 

Stern MP. Diabetes in Hispanic Americans Jji Diabetes Data — Compiled 1983, 
Eds. Harris MI and Hamman R. U.S. Government Printing Office, Washington 
D.C. (in press). 

Hanis CL, Ferrell RE, Barton SA, Aguilar L, Garza-Ibarra A, Tulloch BR, Garcia 
CA, Schull WJ. Diabetes among Mexican Americans in Starr County, Texas. Amer 
J Epidemiol 118:659-72, 1983. 

Stern MP, Gaskill SP. Secular trends in ischemic heart disease and stroke 
mortality from 1970 to 1976 in other whites and Spanish-surnamed individuals 
in Bexar County, Texas. Circulation 58:537-43, 1978. 

Stern, MP, Gaskill, SP, Allen CR Jr., Garza V, Gonzales JL, Waldrop RH. Cardio- 
vascular risk factors in Mexican Americans in Laredo, Texas I. Prevalence of 
overweight and diabetes and distribution of serum lipids. Amer J Epidemiol 
113:546-55, 1981. 

Haffner SM, Rosenthal M, Hazuda HP, Stern MP, Franco LJ. Evaluation of three 
potential screening tests for diabetes mellitus in a biethnic population. 
Diabetes Care 7:347-53, 1984. 

Stern MP, Rosenthal M, Haffner SM, Hazuda HP, Franco LJ. Sex difference in 
the effect of sociocultural status on diabetes and cardiovascular risk factors 
in Mexican Americans: the San Antonio Heart Study. Amer J Epidemiol 120:834- 
51, 1984. 

Stern MP, Gaskill SP, Hazuda HP, Gardner LI, Haffner SM. Does obesity explain 
success prevalence of diabetes among Mexican Americans? Results of the San 
Antonio Heart Study. Diabetologia 24:272-77, 1983. 

Cruz-Vidal M, Costas R, Garcia-Palmieri MR, Sorlie PD, Hertzmark E. Factors 
related to diabetes mellitus in Puerto Rican men. Diabetes 28:300-7, 1979. 

Garcia-Palmieri MR, Costas R, Cruz-Vidal M, Cortes-Alicea M, Colon AA, 
Feliberti M, Ayala AM, Patterne D, Sobrino R, Torres R, Nazario E. Risk 
factors and prevalence of coronary heart disease in Puerto Rico. Circulation 
42:542-9, 1970. 

Hazuda H, Haffner S. Acculturation as a protective factor against diabetes 
in Mexican Americans: San Antonio Heart Study. Diabetes 33 (Suppl 1):30A, 
1984. 

Hazuda H, Haffner S, Stern M, Rosenthal M, Franco L. Effects of acculturation 
and socioeconomic status on obesity and glucose intolerance in Mexican American 
men and women. Amer J Epidemiol 120:494, 1984. 



260 



Relethford JH, Stern MP, Gaskill SP, Hazuda HP. Social class, admixture, and 
skin color variation in Mexican Americans and Anglo Americans living in San 
Antonio, Texas. Amer J Phys Anthropol 61:97-102, 1983. 

Gardner LI, Stern MP, Haffner SM, Gaskill SP, Hazuda HP, Relethford JH, 
Eifler CW. Prevalence of diabetes in Mexican Americans: relationship to 
percent of gene pool derived from native American sources. Diabetes 33:86-92, 
1984. 

Bennett PH. Chronic diseases in the American Indian, with particular reference 
to the Pima Indians of Arizona. Presented at the Woodlands Conference on 
Chronic Diseases among Mexican Americans. Woodlands, TX Dec 2-6, 1984. 

Gonzalez R, Ballester JM, Estrada M, Lima F, Martinez G, Wade M, Colombo B, 
Vento R. A study of the genetical structure of the Cuban population: red 
cell and serum biochemical markers. Amer J Hum Genet 28:585-96, 1976. 

Roseman JM. Diabetes in Black Americans iri Diabetes Data — Compiled 1983, 
Eds. Harris MI and Hamman R. U.S. Government Printing Office, Washington 
D.C. (in press) . 

Malina RM, Little BB, Stern MP, Gaskill SP, Hazuda HP. Ethnic and social 
class differences in selected anthropometric characteristics of Mexican 
American and Anglo adults: the San Antonio Heart Study, Human Biology 
55:867-83, 1983. 

Gam SM. Ten-state nutrition survey, subscapular and triceps fatfold 
data, total U.S.A. Center for Human Growth and Development, University 
of Michigan, Ann Arbor. 

Mueller WH, Joos SK, Hanis CL, Zavaleta AN, Eichner J, Schull WJ. The 
Diabetes Alert Study: grovrtih, fatness and fat patterning, adolescence 
through adulthood in Mexican Americans. Amer J Phys Anthropol 64:389-99, 
1984. 

Joos SK, Mueller WH, Hanis CL, Schull WJ. Diabetes Alert Study: weight 
history and upper body obesity in diabetic and non-diabetic Mexican American 
adults. Annals of Human Biol 11:167-71, 1984. 

Proposed protocol for the clinical trial to assess the relationship between 
metabolic control and the early vascular complications of insulin-dependent 
diabetes. Diabetes 31:1132-3, 1982 

U.K. Prospective Diabetes Study. A 15 center study funded by The Medical 
Research Council and The British Diabetes Association. 



261 



Table 4.1 

PREVALENCE (PERCENTAGE) OF DIABETES IN 
MEXICAN AMERICANS IN LAREDO, TEXAS, 1979 









Newly 


Diagnosed* 






Previously 


Diagnosed* 


Fasting 


Hyperglycemia 




Sex and 






Total 


Age (Years) 


Number 


Percent 


Number 


Percent 


Percent 


Men 












45-54 


3/37 


8.1 


1/37 


2.7 


10.8 


55-64 


7/42 


16.7 


0/42 


0.0 


16.7 


65-74 


5/30 


16.7 


2/30 


6.7 


23.3 


Total, 45-74 


15/109 


13.8 


3/109 


2.8 


16.5 


Age-adjusted 




13.0 




2.7 


15.7 


prevalence' 












Women 












4 5-54 


7/93 


7.5 


0/93 


0.0 


7.5 


55-64 


9/70 


12.9 


3/70 


4.3 


17.1 


65-74 


18/65 


27.7 


2/65 


3.1 


30.8 


Total, 45-74 


34/228 


14.9 


5/228 


2.2 


17.1 


Age- adjusted 




14.0 




2.2 


16.1 


prevalence^ 













*Criteria for previously diagnosed diabetes were history of diabetes together 
with either fasting plasma glucose >^ 140 mg/dl or currently using insulin or 
oral antidiabetic medication; criterion for newly diagnosed diabetes was fast- 
ing plasma glucose >^ 140 mg/dl. 

^Age-adjusted by the direct method to the United States 1970 population. 

Source: Stern, MP, et al. Cardiovascular risk factors in Mexican Americans 
in Laredo, Texas. Am J Epidemiol 113:546-555, 1981. 



262 



Table 4.2 

PREVALENCE (PERCENTAGE) OF NONINSULIN-DEPENDENT DIABETES MELLITUS (NIDDM)* 
IN MEXICAN AMERICANS ACCORDING TO SOCIOECONOMIC STATUS, 
THE SAN ANTONIO HEART STUDY, 1979-82 









Transitional 










Barrio 


Ne 


Lghborhood 




Suburbs 


Sex and 














Age (Years) 


Number 


Percent 


Number 


Percent 


Number 


Percent 


Men 














25-34 


2/50 


4.0 


1/62 


1.6 


0/31 


0.0 


35-44 


3/32 


9.4 


4/51 


7.8 


2/64 


3.1 


45-54 


7/46 


15.2 


9/40 


22.5 


7/64 


10.9 


55-64 


15/50 


30.0 


11/36 


30.6 


3/25 


12.0 


Total, 25-64 


27/178 


15.2 


25/189 


13.2 


12/184 


6.5 


Age-adjusted 














prevalence^ 




13.7 




14.6 




6.1 


Women 














25-34 


1/71 


1.4 


1/92 


1.1 


2/53 


3.8 


35-44 


8/73 


11.0 


5/65 


7.7 


1/73 


1.4 


45-54 


13/75 


17.3 


4/48 


8.3 


2/54 


3.7 


55-64 


27/79 


34.2 


7/38 


18.4 


1/16 


6.3 


Total, 25-64 


49/298 


16.4 


17/243 


7.0 


6/196 


3.1 


Age- adjusted 










* 




prevalence^ 




14.8 




8.2 




3.7 



*NIDDM defined as cases meeting NDDG criteria for diabetes (fasting or OGTT criteria) or, 
for those persons who did not meet NDDG criteria, history of diabetes together with 
current use of insulin or oral antidiabetic agents. 

^Age-adjusted by the direct method to the United States 1970 population. 

Source: Stern, MP, Rosenthal, M, Haffner, SM, Hazuda, HP, Franco, LJ. Sex difference in 

the effects of sociocultural status on diabetes and cardiovascular risk factors in 
Mexican Americans. Am J Epidemiol 120:834-51, 1984. 



263 



Table 4.3 

PREVALENCE (PERCENTAGE) OF NONINSULIN-DEPENDENT DIABETES MELLITUS (NIDDM) 
IN MEXICAN AMERICANS IN STARR COUNTY, TEXAS, 1981 





Previously 


Diagnosed* 


Newly Diagnosed* 




Sex and 










Total 


Age (Years) 


Number 


Percent 


Number 


Percent 


Percent 


Men 












15-24 


0/211 


0.0 


0/211 


0.0 


0.0 


25-34 


3/115 


2.6 


0/115 


0.0 


2.6 


34-44 


3/92 


3.3 


0/92 


0.0 


3.3 


45-54 


7/95 


7.4 


5/95 


5.3 


12.7 


55-64 


11/85 


12.9 


3/85 


3.5 


16.4 


65-74 


8/60 


13.3 


2/60 


3.3 


16.6 


75+ 


4/34 


11.8 


2/34 


5.8 


17.6 


Total, 15-75 


36/692 


5.2 


12/692 


1.6 


6.9 


Age-adjusted 




5.6 




1.9 


7.5 


prevalence 












(15-75 years )^ 












Age-adjusted 




6.2 




2.1 


8.3 


prevalence 
(25-64 years )^ 






















Women 












15-24 


1/285 


0.4 


0/285 


0.0 


0.4 


25-34 


1/254 


0.4 


0/254 


0.0 


0.4 


34-44 


8/210 


3.8 


4/210 


1.9 


5.7 


45-54 


17/204 


8.3 


5/204 


2.5 


10.8 


55-64 


26/142 


18.3 


1/142 


0.7 


19.0 


65-74 


10/94 


10.6 


6/94 


6.4 


17.0 


75+ 


3/50 


6.0 


1/50 


2.0 


8.0 


Total, 15-75 


66/1,239 


5.3 


17/1,239 


1.4 


6.7 


Age- adjusted 




5.7 




1.4 


7.1 



prevalence 
(15-75 years )^ 



Age-adjusted 
prevalence 
(25-64 years )^ 



7.0 



1.3 



8.3 



*Previously diagnosed diabetes defined as medical history of diabetes, or taking 
insulin or oral hypoglycemic drugs, or meeting NDDG criteria. Newly diagnosed 
diabetes defined as all of the following: casual blood glucose > 130 mg/dl, 
4-hour fasting blood glucose >^ 130 mg/dl, and meeting NDDG criteria. 

'Age-adjusted by the direct method to the United States 1970 population. 

Source: Hanis, CL, et al . Diabetes among Mexican Americans in Starr County, 
Texas. Am J Epidemiol 118:659-72, 1983. 



264 



Table 4.4 

PREVALENCE (PERCENTAGE) OF DIABETES IN PUERTO RICAN MEN 
AGED 45 TO 64, PUERTO RICO HEART HEALTH PROGRAM, 1965 





Rural 


Men 


Urban 


Men 


Age (Years) 


Number 


Percent 


Number 


Percent 


45-49 


16/552 


2.9 


113/1,683 


6.7 


50-54 


24/735 


3.3 


174/1,935 


9.0 


55-59 


22/684 


3.2 


134/1,427 


9.4 


60-64 


31/596 


5.2 


134/1,145 


11.7 


Total, 45-64 


93/2,567 


3.6 


555/6,190 


9.0 


Age-adjusted 










prevalence* 




3.5 




9.0 



'^ Age-adjusted by the direct method to the United States 1970 population. 

Source: Cruz-Vidal, M, et al. Factors related to diabetes mellitus in 
Puerto Rican men. Diabetes 28:300-07, 1979. 



265 



Table 4.5 

PREVALENCE (PERCENTAGE) OF PREVIOUSLY AND NEWLY DIAGNOSED 
DIABETES IN PUERTO RICAN MEN AGED 4 5 TO 64, 
PUERTO RICO HEART HEALTH PROGRAM, 1965 



Rural Men Urban Men 

Previously diagnosed 

Euglycemic 1.3 3.6 

Hyperglycemic 0.8 2.8 

Newly diagnosed 1.5 2.6 

Total 3.6 9.0 



Source: Cruz-Vidal, M, et al. Factors related to diabetes mellitus in 
Puerto Rican men. Diabetes 28:300-07, 1979. 



266 



Table 4.6 

PREVALENCE (PERCENTAGE) OF DIABETES, ACCORDING TO RELATIVE WEIGHT, 

IN PUERTO RICAN MEN AGED 45 TO 64, 

PUERTO RICO HEART HEALTH PROGRAM, 1965 





Rural 


Men 


Urban 


Men 




Relative Weight* 


Number 


Percent 


Number 


Percent 


Age 45-49 












<100 


8/545 


1.5 


21/604 




3.5 


100-109 


2/303 


0.7 


29/593 




4.9 


110-125 


13/302 


4.3 


121/1,374 




8.8 


>125 


17/135 


12.6 


115/1,042 




11.0 


Age 55-64 












<100 


10/630 


1.6 


28/592 




4.7 


100-109 


7/279 


2.5 


40/448 




8.9 


110-125 


23/254 


9.1 


107/870 




12.3 


>125 


13/115 


11.3 


93/659 




14.1 





♦Percent of ideal body weight for observed height from Metropolitan Life 
Insurance tables. 

Source: Cruz-Vidal , M, et al. Factors related to diabetes mellitus in 
Puerto Rican men. Diabetes 28:300-07, 1979. 



267 



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268 



Table 4.8 

SEVERITY OF HYPERGLYCEMIA IN MEXICAN AMERICANS 
AND NON-HISPANIC WHITES WITH NIDDM, THE 
SAN ANTONIO HEART STUDY, 1979-82 



Plasma Glucose Concentration 
2-Hours Post Oral Glucose Load 



Less Than 
300 mg/dl 



Greater Than 
300 mg/dl 



Mexican-American diabetics 
Non-Hispanic white diabetics 



50.9% 
76.6% 



49.1% 
23.4% 



269 



Table 4.9 

DISTRIBUTION OF NIDDM IN MEXICAN AMERICANS AND NON-HISPANIC WHITES 
ACCORDING TO DIAGNOSTIC AND TREATMENT STATUS, 
THE SAN ANTONIO HEART STUDY, 1979-82 



Mexican 
American 



Number 



Non-Hlspanlc 
White 



Number 



% 



Newly diagnosed 

Previously diagnosed 
Diet treatment only 
Treatment with oral agents 
Treatment with Insulin 

Mean age at diagnosis 
Mean duration of diabetes 



74 



58.3 



30 



61.2 



17 




13. 


.4 


27 




21, 


.3 


9 




7. 


.1 




43 


yrs 






9.4 


yrs 





12 


24.5 


4 


8.2 


3 


6.1 




49 yrs 




7.5 yrs 



270 



Chapter 5 
DIABETES IN ASIAN AMERICANS 



The Asian-American population in the United States more than doubled 
between 1970 and 1980, rising from about 1,426,000 to more than 3,466,000 
(table 5.1). In the same decade, Chinese Americans assumed the first rank 
among Asian Americans, with a population of more than 812,000, Filipino 
Americans took second, with almost 782,000 persons, and Japanese Americans 
dropped from first to third, with more than 716,000 persons. 

Of the 12 Asian groups enumerated in the 1980 census, Japanese Americans 
are the only group in which detailed studies of the impact of diabetes have 
been undertaken. A recent study by Yu and her colleagues, however, has used 
figures from the 1980 census on the 10 leading causes of death in the United 
States to compute their rank order and proportional mortality in Chinese, 
Japanese, and Filipino Americans. Table 5.2 shows that diabetes was the 
seventh leading cause of death reported in whites, Japanese Americans, and 
Filipinos and the eighth leading cause of death in Chinese Americans. 
Table 5.3 computes the age-adjusted mortality ratio for the three groups in 
relation to whites. 

A study conducted by Sloan in Hawaii in 1958-59 compared the incidence 
and prevalence of diabetes in white, Chinese, Filipino, Japanese, and Korean 
adults, representing about 30 percent of the workforce on the island of Oahu 
(table 5.4). The study found an age-adjusted rate in Filipinos that was 
almost three times as high as the rate in whites. In Japanese and Koreans, 
the rate was only slightly lower than in Filipinos, and the rate in Chinese 
was double that in whites. Rates of incidence bore roughly the same relation 
to the rate in whites. The population studied consisted of approximately 
30,000 persons, of whom jnore than 16,000 were of Japanese ancestry. 

The results of these studies make it clear that in at least four groups 
of Americans of Asian background, diabetes is not only a significant problem, 
but one whose manifestation is disproportionate to its severity in our popu- 
lation as a whole. Because we have more information on Americans of Japanese 
ancestry, the rest of this chapter will summarize the studies that have been 
made in that group. 

Results from the various studies of diabetes in Japanese Americans are 
difficult to compare, partly because of the small number of studies that have 
been carried out and partly because the methods and criteria used are not 
consistent. On the basis of existing knowledge, however, it can be concluded 
that Japanese Americans suffer from the noninsulin-dependent form of the 
disease to a greater degree than either white Americans or Japanese in Japan. 
International surveys of diabetes prevalence have shown IDDM to be much less 
common in Japan than in other nations. Therefore, it seems likely that type I 
diabetes is very uncommon among Japanese Americans. 



271 



Incidence and Prevalence 

The most extensive survey of diabetes among the Japanese, the Hiroshima 
University Study, compared sample populations from Hawaii and Los Angeles 
from 1973 to 1978 and from the prefecture (province) of Hiroshima in Japan 
from 1975 to 1978. Japanese living in rural areas of Hiroshima were selected 
because the majority of Japanese immigrants to the United States had original- 
ly come from rural areas of Japan. Rates of diabetes prevalence in Hawaii 
and Los Angeles were not significantly different and are combined in table 5.5. 
The prevalence rate was 13.9 percent among Japanese in Hawaii and Los Angeles. 
In Hiroshima, the rate was 6.5 percent. 

The finding of a higher rate of diabetes among the immigrant Japanese 
persisted when comparisons were based on matched body-mass index; thus, the 
difference could not be attributed to obesity. Diabetes was diagnosed either 
from the fact that the individual was receiving insulin or oral hypoglycemia 
drugs or from a finding of a serum glucose level of 200 mg/dl or higher 2 
hours after administration of 50 g of oral glucose. 

The Ni-Hon-San study compared Japanese men living in Japan, Honolulu, 
and eight counties in the San Francisco Bay area. The group in Japan comprised 
a 20-percent sample of about 100,000 persons who have been examined every 
2 years since 1958 by the Atomic Bomb Casualty Commission. They represent an 
ambulatory population made up of persons who were exposed to radiation in 
World War II as well as those who were not exposed. The Honolulu group 
consisted of 9,878 men of Japanese ancestry identified from Selective Service 
records. The California group consisted of 3,809 persons and included both 
Japanese who had immigrated to the United States and their children who were 
born in this country. Both the Honolulu and San Francisco groups showed 
higher glucose intolerance than the Japanese group. 

The Honolulu Heart Study examined 8,006 men of Japanese ancestry who 
were living on Oahu in 1965 (table 5.6). Of these, 7,916 men 45 to 64 years 
old were administered 50 g of oral glucose. Men with known diabetes made up 
5.9 percent of the population. An additional 6.7 percent exhibited serum 
glucose levels of 225 mg/dl or more after 1 hour. Those who showed glucose 
intolerance thus represented 12.6 percent of the population studied. 

The Seattle Japanese-American Community Diabetes Study is based on a 
1983 survey of a strictly defined population of Japanese-American men who 
reside in the greater Seattle area, which includes King County. This ongoing 
study is examining the prevalence of diabetes, its associated complications, 
and factors that may be related to the development of diabetes and its com- 
plications. Its goal is to study 250 (about 15 percent) Nisei men (men 
of pure Japanese ancestry who came to the United States before the age of 
6 years and before 1925 or who were born of at least one parent who had 
immigrated after the age of 6 and before 1925). Since health care is easily 
accessible to this group, its availability would not seem to be a factor in 
the study. Of the 214 men sampled in the first year, 12.1 percent reported 
that they had diabetes. 



272 



In 1984, a 75 g oral glucose-tolerance test was given to 74 Nisei men 
involved in the study who were 50 to 70 years old. All 74 initially had 
reported that they did not have diabetes. The results of the test revealed 
that over half of the men showed abnormal glucose tolerance. Only 44.6 per- 
cent were found to have normal glucose tolerance (fasting serum glucose 
<115 mg/dl and 2-hour serum glucose <140 mg/dl); 13.5 percent were diabetic 
(fasting serum glucose >140 mg/dl and/or 2-hour serum glucose M40 mg/dl and 
<200 mg/dl), and 41.9 percent had impaired glucose intolerance (fasting serum 
glucose <140 mg/dl and 2-hour serum glucose M40 mg/dl and <200 mg/dl). In 
contrast, the HANES for 1976-80 found undiagnosed diabetes in 4.7 percent of 
the general population 40 to 59 years old and in 9.3 percent of those 60 to 
74 years old; the rates of impaired glucose tolerance in the same groups were 
6.4 and 10.0 percent, respectively. 

Recent unpublished data from Tokyo indicate that 5.4 percent of men 
40 years old or older have diabetes, and 5.6 percent exhibit impaired glucose 
tolerance. In view of the fact that American women exhibit a higher degree 
of diabetes than American men, the rate found in Japanese women over 40 years 
old is of interest: the same study found diabetes in 2.5 percent of Tokyo 
women and impaired glucose tolerance in 4.0 percent. 

Although no conclusions are possible from the available data, the rate 
of diabetes in Japanese Americans appears to be higher than both the rate 
in the population as a whole and the rate in Japan. Japanese-American men 
40 years old and older may exhibit a rate of diabetes as high as 10 to 14 per- 
cent; the rate of impaired glucose tolerance may be as high as 50 percent. 

Complications and Mortality 

The complications of diabetes are an important factor in the mortality 
associated with the disease. A study of mortality among Americans of Chinese, 
Japanese, and Filipino ancestry compared death rates in Asians who had immi- 
grated to the United States with death rates in the same ethnic groups born 
in this country. Age-adjusted ratios (table 5.7) showed that the rate of 
death from diabetes in the immigrants is consistently higher than that in the 
native born. The ratios were as follows: Chinese, 1.51; Japanese, 2.09; and 
Filipinos, 2.42. 

Several studies have found lower rates of some complications of diabetes 
in Japanese in Japan than in Japanese Americans. In Hawaii, Japanese Ameri- 
cans with diabetes had a mortality rate from vascular disease of 74.5 percent; 
whites with diabetes showed a similar rate (75.8 percent). Two studies in 
Japan found corresponding rates among people with diabetes to be 51.1 and 
53.8 percent. The difference was apparently due to a much lower rate of 
death from ischemic heart disease. The Hiroshima University Study found that 
Hawaiian Japanese with diabetes exhibited higher rates of hypercholesterolemia, 
hypertriglyceridemia, hypertension, and ischemic heart disease than Japanese 
from Hiroshima. 

The Seattle study compared a small sample of Japanese-American men who 
had diabetes with male diabetes patients in Tokyo. Of the Seattle sample, 
33 percent showed plasma cholesterol levels of 250 mg/dl or higher; the rate 



273 



in the sample in Tokyo was 5 percent. More Seattle men (20 percent) than 
Tokyo men exhibited ischemic electrocardiographic abnormalities. At the same 
time, the Tokyo sample had significantly lower creatinine clearance and a 
higher level of diabetic retinopathy. A preliminary analysis of data from 
the Seattle group has found both abnormal renal function and diabetic reti- 
nopathy to be extremely rare. Rates of both retinopathy and proteinuria have 
also been found higher in Japan than in England. Of the men in the Seattle 
study, 73.3 percent exhibited hypertension, but peripheral arterial disease 
appears quite rare. 

The conclusion from these preliminary findings is that although Japanese 
Americans appear to exhibit a higher degree of ischemic heart disease, micro- 
vascular disease as exemplified in retinopathy and nephropathy may be more 
common in Japan. 

Risk Factors 

Diet . The differences in diabetes rates between Japanese Americans and 
the population in Japan may in part be explained by differences of diet. The 
diet recommended for all Americans would require 50 to 60 percent of total 
calories to be derived from carbohydrates and only 30 to 38 percent from 
fats. The Japanese diet includes about that proportion of carbohydrates and 
even less fat. The diet maintained by Japanese American men in the Seattle 
study who do not have diabetes is closest to these standards. The diet of 
the men who have diabetes is the farthest from them. The diet of men diag- 
nosed as exhibiting impaired glucose tolerance falls between that of the two 
other groups . 

The Hiroshima University Study found that in the Japanese Americans in 
Hawaii and Los Angeles, the intake of total fat, animal fat, animal protein, 
and simple carbohydrates was higher than that among the Japanese in Hiroshima. 
In addition, the study found that the intake of total carbohydrates and com- 
plex carbohydrates was lower. Total energy intake, adjusted for obesity 
(defined by body-mass index) as well as for physical activity, was about the 
same. Similar observations were made in the Ni-Hon-San and Seattle studies. 

Such differences in diet may well be related to the higher rate of 
diabetes, hypercholesterolemia, and ischemic heart disease found in Japanese 
Americans compared with native Japanese. 

Although Japanese American men are not on the whole excessively over- 
weight, their relative adiposity is higher than that of men the same age in 
Japan. Intra-abdominal adipose tissue has been reported to be more resistant 
to insulin than subcutaneous adipose tissue. The Seattle study has used 
computer-assisted tomography (CAT) to measure patterns of fat distribution in 
the abdomen, chest, and thigh. It was found that Japanese-American men with 
diabetes show a larger cross-sectional area of fat in the abdominal area than 
nondiabetic Japanese Americans, as well as a higher ratio of cross-sectional 
subcutaneous fat in the thorax to that in the thigh. 

Preliminary data also suggest that Japanese Americans with electrocardio- 
graphic indications of ischemic abnormalities tend to exhibit higher fasting 
plasma insulin levels than Japanese Americans with normal electrocardiograms. 



274 



Psychological and Sociocultural Factors . Relatively little attention 
has been given to the possible role of psychological and sociocultural factors 
in the etiology of diabetes. The history of Japanese Americans reveals a 
unique experience of immigration, assimilation, forcible relocation during 
World War II, and postwar rebuilding and reassimilation. Consequently, a 
study of the psychological factors that have affected them may well yield 
clues to the course of diabetes in the group. 

Among the minority groups in the United States, Japanese Americans have 
undergone a unique development. During the wartime dislocations, when 
American officials proved unwilling to deal with the traditional leaders of 
the Japanese families, many of these elders abdicated in favor of their sons, 
who thus assumed family responsibilities at an unaccustomed early age. The 
result in many cases has been a situation that is labeled as "status incon- 
gruity," which is characterized by discrepancies in various indicators of 
socioeconomic status (levels of education, occupation and income, membership 
in organizations, and quality of housing). Such discrepancies often indicate 
that a family's status has changed within a generation. The tensions and 
conflicts that result from status incongruity have been found to be associated 
with the development of cardiovascular disease. 

A possible association of status incongruity with diabetes is one of the 
areas being explored by the Seattle study. Data to date suggest that Japanese 
Americans with diabetes for the most part have lower levels of education — 
usually technical school level — than those without diabetes, but nevertheless 
often head households whose gross incomes are comparable to those of nondia- 
betic Japanese Americans. 

Other preliminary findings suggest that sociocultural ties with other 
Japanese Americans may not be as close among the men with diabetes and that 
the same men are less open to association with the non-Japanese community. 

This limited information is quite preliminary and certainly cannot be 
considered as definitive evidence. Nonetheless it supports the notion that 
psychological and sociocultural influences in the development of diabetes 
represent an important and largely untapped area of research. 

Prevention 

If environmental and psychosocial factors are involved in the patho- 
genesis of diabetes, specific intervention measures may be feasible. The 
further elucidation of these relationships is therefore an important area for 
future research. These future studies should include a careful comparison 
with the native Japanese population as well as longitudinal studies within 
the Japanese-American population. Furthermore, similar research should be 
done in other populations for whom high rates of diabetes are present. 

It is anticipated that results of such research will lead to a better 
understanding of the pathogenesis of diabetes and specific therapeutic recom- 
mendations for people with diabetes, with implications not only for the 
Japanese-American population, but also for other populations. Such studies 
among the Sansei (children of the Nisei) may be particularly enlightening in 
explaining the high prevalence rate of diabetes observed among the Nisei. 



275 



SOURCES 



Sloan, N.R. Ethnic Distribution of Diabetes Mellitus in Hawaii. JAMA 
183:419-424, 1963. 

Aagenaes, 0., E. Wannag, and T. Kitagawa. Childhood Diabetes in Tokyo and 
Oslo. Diabetologia 25:135, 1983. 

Yano, K. , A. Kagan, D. McGee, and G.G. Rhoads. Glucose Intolerance and 
Nine-year Mortality in Japanese Men in Hawaii. Am. J. Med. 72:71-80, 1982. 

Kawate, R. , M. Yamakido, and Y. Nishimoto. Migrant Studies among the Japanese 
in Hiroshima and Hawaii. In: Diabetes 1979, Proceedings of the 10th Congress 
of the International Diabetes Federation, W.K. Waldhausel (ed.). Excerpta 
Medica, Amsterdam, 1980, pp. 526-531. 

Harris, M. The Prevalence of Diagnosed Diabetes, Undiagnosed Diabetes, and 

Impaired Glucose Tolerance in the United States. In: Genetic Environmental 

Interaction in Diabetes Mellitus, J.S. Melish, J. Hanna, and S. Baba (eds.). 
Excerpta Medica, Amsterdam, 1982, pp. 70-76. 

Goto, Y. Personal communication. 

Kawate, R. , M. Yamakido, Y. Nishimoto, P.H. Bennett, R.F. Hamman, and 

W.C. Knowles. Diabetes Mellitus and Its Vascular Complications in Japanese 

Migrants on the Island of Hawaii. Diab. Care 2:161-170, 1979. 

Hirate, Y., and T. Mihara. Principal Causes of Death Among Diabetic Patients 
in Japan from 1968 to 1970. In: Diabetes Mellitus in Asia, S. Baba, Y. 
Goto, and I. Fukui (eds.). Excerpta Medica, Amsterdam, 1976, pp. 91-97. 

Mihara, T. , H. Ohashi, and Y. Hirata. A Prospective Study of 1,629 Diabetics 
in Tokyo. In: Genetic Environmental Interaction in Diabetes Mellitus, J.S. 
Melish, J. Hanna, and S. Baba (eds.). Excerpta Medica, Amsterdam, 1981, 
pp. 107-111. 

Fujimoto, W.Y., K. Hershon, J. Kinyoun, W. Stolov, C. Weinberg, K. Ishi wata, 
H. Kahinuma, Y. Kanazawa, and N. Kuzuya. Type II Diabetes Mellitus in Seattle 
and Tokyo. Tohoku J. Exp. Med., 1984, in press. 

Bennett, P.H. and M. Miller. Vascular Complications of Diabetes in American 
Indians, Japanese and Caucasians. In: Diabetes Mellitus in Asia, S. Baba, 
Y. Goto, and I. Fukui (eds.). Excerpta Medica, Amsterdam, 1976, pp. 202-207. 

Kagan, A., B.R. Harris, W. Winkelstein, Jr., K.G. Johnson, H. Kata, S.L. 
Syme, G.G. Rhoads, M.L. Gay, M.Z. Nichaman, H.B. , Hamilton, and J. Tillotson. 
Epidemiologic Studies of Coronary Heart Disease and Stroke in Japanese men 
Living in Japan, Hawaii and California: Demographic, Physical, Dietary and 
Biochemical Characteristics. J. Chron. Dis. 27:345-364, 1974. 



276 



Arky, A,, J. Wylie-Rosett , and B. El Beheri. Examination of Current Dietary 
Recommendations for Individuals with Diabetes Mellitus. Diabetes Care 5:59-63, 
1982. 

Jenkins, CD. Recent Evidence Supporting Psychologic and Social Risk Factors 
for Coronary Disease. New Engl. J. Med. 294:987-994, 1033-1038, 1976. 

Bruhn, J.G., B. Chandler, M.C. Miller, S. Wolf, and T.N. Lynn. Social 
Aspects of Coronary Heart Disease in Two Adjacent, Ethnically Different 
Communities. Am. J. Public Health 56:1493-1506, 1966. 

Shuman, W.P., L.L. Ne well-Morris, D.L. Leonetti , P.W. Wahl, V.M. Moceri, A. A. 
Moss, and W.Y. Fujimoto. Abnormal Body Fat Distribution in Diabetic Males 
Detected by Computed Tomography. Submitted for publication. 

Bolinder, J., L. Kager, J. Ostman, and P. Arner. Differences at the Receptor 
and Postreceptor Levels between Human Omental and Subcutaneous Adipose Tissue 
in the Action of Insulin on Lipolysis. Diabetes 32:117-123, 1983. 

Yu, S., C.F. Chang, W. Liu, S. Kan. Asian-White Mortality Differentials. 
Unpublished paper commissioned by the Subcommittee on Diabetes of the Task 
Force on Black and Minority Health. 



277 



Table 5.1 
ASIAN POPULATION, 1980 AND 1970 



Number 



Percent 



United States 



1980* 


1970 


1980* 


1970 


3,466,421 


1,426, 


,148 


100.0 


100.0 


812,178 


431, 


,583 


23.4 


30.3 


781,894 


336, 


,731 


22.6 


23.6 


716,331 


588, 


,324 


20.7 


41.3 


387,223 




NA 


11.2 


— 


357,393 


68, 


,510t 


10.3 


4.9t 


245,025 




NA 


7.1 


— 


166,377 




NA 


4.8 


— 


47,683 




NA 


1.4 


— 


45,279 




NA 


1.3 


— 


16,044 




NA 


0.5 


— 


15,792 




NA 


0.5 


— 


9,618 




NA 


0.3 


— 


5,204 




NA 


0.2 


~ 


26,757 




NA 


0.8 


— 



Total Asian Population 

Chinese 

Filipino 

Japanese 

Asian Indian 

Korean 

Vietnamese 

Other Asians 

Laotian 

Thai 

Cambodian 

Pakistani 

Indonesian 

Hmong 

All Other 



*Data based on sample. 

'The 1970 data on the Korean population excluded the State of Alaska. 

Source: Bureau of the Census (1983). 



278 



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279 



Table 5.3 

AGE-ADJUSTED RACE-MORTALITY RATIOS FOR SPECIFIC CAUSE OF DEATH: 

UNITED STATES, 1980 



Causes of Death 



Chinese 



Japanese 



Filipino 



Heart Disease 

Cancer 

Cerebrovascular Disease 

Accidents 

Chronic Obstructive Pulmonary Disease 

Pneumonia and Influenza 

Diabetes Mellltus 

Chronic Liver Disease and Cirrhosis 

Atherosclerosis 

Suicide and Self-Infllcted Injury 



0.54 


0.42 


0.42 


0.76 


0.60 


0.40 


0.76 


0.76 


0.66 


0.34 


0.44 


0.39 


0.50 


0.34 


0.31 


0.81 


0.73 


0.59 


0.81 


0.64 


0.49 


0.42 


0.34 


0.29 


0.57 


0.41 


0.25 


0.64 


0.62 


0.30 



Note: Ratios are calculated for each specific cause of death by dividing the age- 
adjusted death rate of a specified ethnic group by the age-adjusted death rate of 
the white population. 

Source: Unpublished data from the National Center for Health Statistics, computed 
by Yu et al. 



280 



Table 5.4 
DIABETES MELLITUS AMONG WHITES AND ASIANS IN HAWAII (1958-59) 





Total Screened 
Number 


Diabetes 


Diagnosed 


Diabetes Rate/1 
Total 


,000 Persons* 


Race 


Total Number 


New 


Known 


New 


White 


4,473 


49 


32 


17 


7.3 


4.8 


Chinese 


3,755 


67 


45 


22 


14.6 


10.3 


Filipino 


4,321 


150 


99 


51 


21.8 


15.5 


Japanese 


16,134 


307 


200 


107 


20.1 


12.6 


Korean 


539 


10 


8 


2 


19.7 


11.7 


Total 


38,103 


819 


492 


327 


18.4 


11.0 



*Age-adjusted rates; the Oahu civilian labor force, 14 years of age or over in 1950, 
was the standard chosen. 

Source: Sloan, NR. Ethnic distribution of diabetes mellitus in Hawaii. JAMA 
183:419-24, 1963. 



281 



Table 5.5 
PREVALENCE OF RATES OF DIABETES,* JAPANESE AMERICANS VERSUS NATIVE JAPANESE 



Sex- Age 
(Years) 



Hawall-Los Angeles (1973-78) 



Hiroshima (1975-78) 



Number of 
Subjects 



Number 
Diabetic 



Percent 
Diabetic 



Number of Number Percent 
Subjects Diabetic Diabetic 



Male 



15-39 


53 








12 


1 


8.3 


40-59 


159 


16 


10.1 


138 


4 


2.9 


60-96 


284 


55 


19.4 


158 


12 


7.6 


All 


496 


71 


14.3 


308 


17 


5.5 



Female 



15-39 


70 


4 


5.7 


28 





0.0 


40-59 


254 


25 


9.8 


210 


10 


4.8 


60-96 


329 


69 


21.0 


233 


24 


10.3 


All 


653 


98 


15.0 


471 


34 


7.2 



Total 



15-39 




123 


40-59 




413 


60-96 




613 


All 




1149 


Age- and 






sex- ad jus 


ted 




rate 







4 

41 

124 

169 



3.3 
9.9 

20.2 
14.7 

13.9 



40 
348 
391 
779 



1 
14 
36 
51 



2.5 
4.0 
9.2 
6.5 

6.5 



*Serum glucose >200 mg/dl at 2 hours after 50 g oral glucose load, or under 
treatment with insulin or oral hypoglycemic agent. 

Source: Kawate, R, Yamakido, M, Nishimoto, Y. Migrant studies among the 

Japanese in Hiroshima and Hawaii. In: Diabetes 1979, Proceedings 
of the 10th Congress of the International Diabetes Federation, Walk- 
hausel, WK (ed). Excerpta Medica, Amsterdam, 1980, pp 526-531. 



282 



Table 5.6 

AGE DISTRIBUTION OF GLUCOSE INTOLERANCE AMONG JAPANESE 
AMERICAN MEN IN HAWAII (1965-68) 





sars) 


Known 
Diabetes* 


Undiagnosed 
Asymptomatic 
Hyperglycemiat 

Number (Percent) 


Normogl 
Number 


.ycemiaf 


Age (Y( 


Number 


(Percent) 


(Percent) 


45-49 






57 




116 




1,642 




50-54 






162 




179 




2,420 




55-59 






113 




107 




1,359 




60-64 






101 




91 




1,128 




65-68 






35 




40 




366 




Total, 


45- 


■68 


468 


(5.9) 


533 


(6.7) 


6,915 


(87.4) 



*Serum glucose >225 mg/dl at 1 hour after 50 g oral glucose load. 

tMedical history of diabetes (treated). 

TPersons not meeting above criteria. 

Source: Yano, K, Kagan, A, McGee, D, and Rhoads, GG. Glucose intolerance and 
nine year mortality in Japanese men in Hawaii. Am J Med 72:71-80, 
1982. 



283 



Table 5.7 

AGE-ADJUSTED NATIVITY-MORTALITY RATIOS FOR 10 LEADING CAUSES OF DEATH: 

UNITED STATES, 1980 



Causes of Death 



Chinese 



Japanese 



Filipino 



1. 
2. 
3. 
4. 
5. 
6. 
7. 
8. 
9. 
10. 



Heart Disease 

Cancer 

Cerebrovascular Disease 

Accidents 

Chronic Obstructive Pulmonary Disease 

Pneumonia and Influenza 

Diabetes Mellitus 

Chronic Liver Disease and Cirrhosis 

Atherosclerosis 

Suicide and Self-inflicted Injui^ 



1.98 


3.04 


2.67 


2.41 


2.82 


1.63 


2.93 


4.21 


2.76 


2.13 


2.94 


2.29 


3.31 


2.88 


1.75 


2.29 


4.37 


2.92 


1.52 


2.09 


2.42 


2.50 


4.95 


2.06 


2.75 


6.38 


0.93 


2.71 


2.69 


1.15 



Note: Ratios are calculated, for each specific cause of death, by dividing the age-adjusted 
death rate of a specified ethnic group by the age-adjusted death rate of the white population 

Source: National Center for Health Statistics, published and unpublished data computed by 
Yu et al. 



284 



Chapter 6 

PREVENTION AND CONTROL 

As documented in the preceding chapters, the burden of diabetes falls 
most heavily on some of the most dependent segments of minority society — the 
aged, the poor, women, and Native Americans. The cost to them, in terms of 
ill health, suffering, and medical care, is overwhelming. The cost to the 
Nation, in terms of economic loss, is almost equally as severe. The National 
Diabetes .Data Group estimates that the direct medical costs of diabetes are 
about $7.4 billion a year, and the indirect costs — which are measured as lost 
productivity from person-years — are another $6.3 billion. 

Diabetes is a major factor in hospitalizations and physician visits. 
People with diabetes are more than twice as likely to be hospitalized com- 
pared with the population as a whole. According to NCHS data, diabetes as 
the first listed diagnosis at discharge accounted for almost 7 million days 
of hospitalization. As one of seven listed discharge diagnoses, diabetes was 
related to almost 25 million hospital days in that year. Diabetes was the 
primary diagnosis in 1.66 percent (9.6 million) of visits to physician's 
offices in 1980, and diabetes was included in the diagnosis in 2.82 percent 
(16.9 million) of visits for other conditions. 

Employed people with diabetes lose an average of 10.8 workdays per year. 
NCHS estimates indicate that each year, 37,500 person-years are lost because 
of diabetes. Women who do not work outside of the home lost an estimated 
53,000 person-years, and 116,300 person-years are lost because of inability 
to work because of diabetes. 

Diabetes as an "underlying cause of death" on death certificates accounts 
for the loss of 145,000 years of life before age 65, according to NCHS data. 
When listed as one of several causes of death, diabetes is associated with an 
additional loss of 411,000 years of life. 

Prevention 

A prevention-oriented approach to diabetes control encompasses three 
levels of strategy: primary prevention, to prevent the disease from occur- 
ring when possible; secondary prevention, to prevent acute complications and 
the appearance of chronic complications through appropriate patient and pro- 
fessional education, therapy, and medical followup; and tertiary prevention, 
to decrease the mortality and morbidity resulting from the acute and chronic 
complications by early detection and the application of prompt, effective 
treatment. 

Primary prevention — intervention before diabetes occurs — could have a 
major impact on the incidence and prevalence of the disease and thus on its 
human and economic costs. Some 75 to 80 percent of people with NIDDM, the 
most prevalent form of diabetes in minorities, are obese. As noted earlier, 
50 percent of NIDDM may be preventable through weight control, diet, and 
physical activity. If so, the prevention of obesity could forestall some 
180,000 new cases of diabetes a year. Since an estimated 50 percent of women 



285 



with gestational diabetes are obese, about 33 percent of the disease could 
be prevented, an additional saving of 28,000 cases. In view of the high 
prevalence of obesity in minorities affected by diabetes, weight control 
in such groups assumes great importance. 

The population as a whole has responded poorly to efforts to promote 
weight control, however. As a result, most efforts in diabetes control have 
focused on secondary and tertiary prevention. Many areas of intervention are 
possible. A news report from Carter Center Health Policy Project indicates 
the following: 

• Education in self -management skills could reduce the incidence of 
ketoacidosis by up to 70 percent, preventing about 50,000 hospitali- 
zations a year. 

• Maintenance of glycemic control in women before conception and 
through gestation could prevent about 500 serious congenital mal- 
formations a year and could significantly reduce morbidity and 
mortality associated with diabetic pregnancies. 

• Detection and control of hypertension in diabetic patients could re- 
duce the incidence of stroke by 75 to 90 percent, coronary heart 
disease by 25 to 50 percent, and peripheral vascular disease by 30 to 
60 percent. 

• Cessation of smoking by people with diabetes could reduce the inci- 
dence of stroke by 5 percent, coronary heart disease by 10 percent, 
and peripheral vascular disease by 30 percent. 

• Early diagnosis and laser photocoagulation therapy for proliferative 
retinopathy could reduce severe visual loss by more than 50 percent. 

• Antihypertensive therapy could reduce by more than 50 percent the 
rate of progression of diabetic nephropathy, thus delaying or prevent- 
ing the development of diabetic end-stage renal disease. 

• Optimum foot care on the part of health care professionals and patients 
could reduce amputations by more than 50 percent. 

Control 

Legislation, institutions, and programs have been created to make pos- 
sible an aggressive approach to diabetes prevention and control. The national 
response to diabetes has become a model for programs of intervention in 
chronic disease. The effort involves the skills and contributions of many 
groups: consumers, health care professionals, academia, voluntary agencies, 
labor, industry, third-party payers, and government. 

In 1974, Congress enacted the National Diabetes Mellitus Research and 
Education Act and established the National Commission on Diabetes. A year 
later, the Commission submitted its report, the Long-Range Plan to Combat 
Diabetes, which put forth a national plan to foster diabetes research and to 



286 



translate research findings into clinical practice. A national program for 
diabetes was initiated that included the establishment of the National Diabetes 
Advisory Board, the National Diabetes Data Group, the National Diabetes 
Information Clearinghouse, Diabetes Research and Training Centers, and Diabetes 
Endocrinology Research Centers. All but one of these programs are operated 
within the National Institute of Arthritis, Diabetes, and Digestive and 
Kidney Diseases, which has the major responsibility for basic and clinical 
research on diabetes. The National Diabetes Advisory Board, which advises 
Congress and the Secretary of Health and Human Services on the implementation 
of the long-range plan, functions as part of the office of the Director of 
the National Institutes of Health. 

Diabetes-related activities are carried out by other NIH agencies and by 
other components of the Federal Government , such as the Centers for Disease 
Control, the Indian Health Service, and the Veterans Administration. All 
Federal activities in diabetes are coordinated by the Diabetes Mellitus 
Interagency Coordinating Committee, which was established by Congress and 
provides a forum for cooperation among Federal agencies and a mechanism for 
monitoring progress. In addition, state and local health agencies and 
numerous voluntary and professional organizations that are involved in 
diabetes care and in serving people with diabetes have joined the national 
effort to combat diabetes and have made important contributions. 

This cooperative effort on the part of the public and private sectors 
has resulted in the development of a number of effective approaches to dia- 
betes control. For example, state health departments participating in the 
CDC's National Diabetes Control Program are involved in community programs 
to demonstrate effective strategies for the control of diabetes. State pro- 
grams have proved the cost-effectiveness of education programs for outpatients. 
For example, the Maine Ambulatory Diabetes Education Program has shown that 
savings in hospitalization costs may amount to as much as three times the 
cost of education programs. As a result, several states have obtained third- 
party reimbursements for outpatient education. 

CDC also helped develop innovative projects such as one in Mississippi 
that involves screening for diabetic eye disease in health department clinics. 
Linkages have also been established with other national programs, such as 
those concerned with hypertension, maternal and child health, and Native 
American health, as well as with community and voluntary programs whose 
purpose is to reduce smoking and encourage weight reduction. 

Thus, the laws, institutions, and programs are in place to focus on the 
problem of diabetes in minorities. As chapters 2 through 5 have shown, our 
understanding of the problem in minority groups lacks the depth and lacks the 
basis on rigorous research that are evident in our knowledge of the problem 
of diabetes in the general population. Each minority group has its own 
characteristics, poses its own problems, and will require special solutions 
based on its particular needs. With the exception of the Model Diabetes 
Health Care Program of the Indian Health Service, few programs have addressed 
the specific problems in minorities. 



287 



Chapters 2, 3, 4, and 5 have pointed out the effect of socioeconomic 
factors on the pathogenesis of diabetes in blacks, Native Americans, Hispanics, 
and Japanese Americans and on the response to both preventive and therapeutic 
measures. Mexican Americans, for example, have been found to respond more 
positively to educational and therapeutic efforts that use the Spanish lan- 
guage and are sensitive to Hispanic-American cultural values. On the other 
hand, the Seattle study suggests that the problem in Japanese Americans may 
be compounded by the sociocultural effect known as "status-incongruity." 

The successful nationwide implementation of programs focusing on American 
minority groups places special responsibilities on professionals and patients. 
Such programs require careful consideration of the effects of professional- 
patient interactions — including professional competence and knowledge, patient 
education, intervention therapies, and level of patient adherence — as well as 
an understanding of the natural history of diabetes in terms of mortality, 
morbidity, and costs. 

Three diabetes care programs developed in the past 20 years can serve as 
examples. All three programs involved predominantly minority populations and 
stressed a prevention-oriented approach that emphasized early diagnosis, op- 
timal medical evaluation, patient education, and access to continuing care 
from a team of trained professionals. Two of the programs are still in 
operation. 

The program at the Los Angeles County Hospital, which ran from 1964 to 
1980, served Mexican Americans. Patients had continuing access to health 
care providers by telephone or through drop-in visits. The program was 
effective in reducing hospitalization for acute and chronic complications 
because of its outpatient care services. The programs at the Memphis City 
Hospital in Tennessee and at Grady Memorial Hospital in Atlanta, Georgia, 
were begun in 1962 and 1968, respectively. Both serve primarily black, 
medically indigent patients. In both programs, specially trained nurses, 
primarily from the public health sector, were mobilized to assist physicians 
in an organized program to provide continuing access to care for individuals 
with chronic disease. For more than 15 years, both programs have collected 
and evaluated data on care and outcome. These data have been reported in a 
series of publications (see sources). 

Initially, each program carried out a prospective "needs assessment" to 
identify its requirements and to define its aims and goals. Both programs 
noted important gaps in the services that were then available to persons 
with diabetes. On the basis of these assessments, strategies were developed 
to expand personnel and facilities to provide a prevention-oriented program 
of services for early detection, patient education, optimal therapy, and 
continuing followup care. The hypothesis that was tested and found valid 
in both programs was that a prevention-oriented approach to diabetes is 
more effective therapeutically and more cost-effective than a crisis-oriented 
approach. 

, Both programs published defined policies and procedures. These included 
the collection of a complete data base, evaluation, education, and continuing 
access to followup care. The primary contact professional in each program 
was a specifically trained nurse, who was accessible to all patients. The 



288 



nurse was backed up by a physician and dietitian. The Atlanta program also 
included a podiatrist. 

Processes of care differed in the two programs. The Memphis program used 
diet therapy alone (25 percent), diet and oral agents (50 percent), and 
insulin (25 percent). The program at Grady Memorial Hospital used short-terra 
fasts and diet alone (81 percent) or diet and insulin (19 percent). The oral 
agents sulfonylurea or phenformin were not prescribed after 1970 in the 
Atlanta program. (Obese patients in Atlanta lost significantly more weight 
than those in Memphis.) 

Results thus far have been significant. In both programs, plasma glucose 
levels decreased in more than 70 percent of the patients participating from 
1970 to 1979. 

Incidence of diabetic ketoacidosis decreased by 60 percent in Memphis, 
and severe diabetic ketoacidosis decreased by 78 percent in Atlanta. Ampu- 
tations decreased by 68 percent in Memphis and by 50 percent in Atlanta. 
These two audited outcomes alone accounted for a marked decrease in days of 
hospitalization in both programs. The Atlanta program has saved Grady 
Memorial Hospital more than $11 million. The Memphis program has decreased 
hospitalizations, diabetic ketoacidosis, and amputations and enjoys a similar 
level of cost-effectiveness. Since mortality ratios from the period before 
the programs began are not available, it is not possible to determine whether 
the programs decreased mortality. 

When subjected to eight categories of evaluation (table 6.1), the Memphis 
and Atlanta programs were found efficacious in four, partly efficacious in 
one, probably efficacious in one, and not efficacious in one. Efficacy could 
not be determined in one. 

Since the inception of the Grady Memorial Hospital program, Medicare, 
Medicaid, and some private health insurance companies have paid for patient 
education as an integral part of continuing care. 

These two programs have set precedents for the planning and implementa- 
tion of diabetes care and patient education programs for minorities. Planners 
of new programs can benefit from the experience of the Memphis and Atlanta 
programs, although each must assess the needs of the population to be served 
before committing facilities and personnel. Strategies, facilities, and 
processes of care then can be planned, and provision can be made for auditing 
and evaluation outcomes. 

A truly epidemiologic approach to the problem of bringing health care to 
people with diabetes, particulary those who are members of minority groups, 
must be based on the gathering, exchange, and use of information. For this 
reason, a number of principles have been developed as guidelines. At a minimum, 
a program designed to provide direct care to diabetic persons should include 
the following aspects in its operational agenda: 

• To identify and report the extent of diabetes in the population it 
serves . 



289 



To ensure that its work is based on accepted standards of diagnosis 
and care. 

To establish programs of education at its sites for both patients and 
professionals, when possible, through financing from third parties. 

To encourage teamwork among physicians, nurses, nurse-practitioners, 
nutritionists, social workers, health-educators, and outreach workers, 

To ensure that all programs of education for health professionals 
include diabetes and emphasize accepted standards of care. 



290 



SOURCES 

Etzwller PD: Who's teaching the diabetic? Diabetes 16:111-117, 1967. 

Watkins JD, Williams TF, Martin DA, Hogen MD, Anderson E: The clinical 
picture of diabetic control studied in four settings. Am J Public Health 
57:452, 1967. 

Williams TF, Anderson E, Watkins JD, Coyler: Dietary errors made at home 
by patients with diabetes. J Am Diet Assoc 51:19, 1967. 

Miller LV, Goldstein J: More efficient care of diabetic patients in the 
country-hospital setting. N Engl J Med 285:1388, 1972. 

Runyan JW Jr., Vander Zwaag R, Joyner MB, et al. The Memphis diabetes 
continuing care program. Diabetes Care 3:382-386, 1980. 

Davidson JK: Educating diabetic patients about diet therapy. Int Diabetes 
Fed Bull 20:1, 1975. 

Knowler WC, Bennett PH, Pettitt D J , Savage P J : Obesity and diabetes in Pima 
Indians: the effects of parental diabetes on the relationship of obesity and 
the incidence of diabetes. In Melish JS, Hanna J, Baba S, eds . , Genetic 
Environmental Interaction in Diabetes Mellitus, Excerpta Medica, Amsterdam, 
1982, pp 95-100. 

Conference on Financing Quality Health Care for Persons with Diabetes, Oct. 
22-24, 1984, Airlie House, Airlie, Virginia. 

Herman WH, Teutsch SM, Geiss LH: Carter Center Health Policy Project — Closing 
the Gap. Health Problem: Diabetes Mellitus, Nov. 26-28, 1984, Atlanta, Georgia. 

Davidson JK: The Grady Memorial Hospital diabetes unit ambulatory care pro- 
gram. In Assal J PH, Assal M, Berger N, Canivet Gay & J, eds., Excerpta 
Medica, Amsterdam-Oxford-Princeton, 1982, pp 286-297. 

Davidson JK: The Grady Memorial Hospital programme in diabetes in epidemio- 
logical perspective. In Mann JI, Pyorala K, Teuscher A, eds., Churchill 
Livingstone, Edinburgh, 1983, pp 332-341. 

Vander Zwaag R, Runyan JW Jr., Davidson JK, Delcher HK, Mainzer I, Baggett 
HW: A cohort study of mortality in two clinic populations of patients with 
diabetes mellitus. Diabetes Care 6:341-346, 1983. 

Davidson JK, Vander Zwaag R, Cox CL, Delcher HK, Mainzer I, Baggett H, Runyan 
JW: The Memphis and Atlanta continuing care programs for diabetes. II. Com- 
parative analyses of demographic characteristics, treatment methods, and 
outcomes over a 9-10 year follow-up period. Diabetes Care 7:25-31, 1984. 

Davidson, JK, Runyan JW: The efficacy of patient education in the Memphis 
and Atlanta Continuing Care Programs for diabetes. Diabetes Care (submitted 
for publication, 1984). 



291 



Davidson JK, Runyan JW: The efficacy of patient education in the Memphis and 
Atlanta Continuing Care Programs for diabetes. Submitted to Diabetes Care for 
publication. Diabetes Care, 198A. 

Davidson JD: Non-Insulin Dependent Diabetes Mellitus. (Ed.) Davidson JK. In: 
Clinical Diabetes Mellitus: A Problem-Oriented Approach. Thieme-Stratton, 
Inc., New York, New York, to be published 1985. 

Mulhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L, Kunz A, 
Schernthaner G, Scholz V, Voss HE: Bicentic evaluation of a teaching and 
treatment programme for type I diabetic patients. Improvement of metabolic 
control and other measures of diabetes care for up to 22 months. Diabetologia 
25:470-476, 1983. 

Diabetes In America: Diabetes Data Compiled 1984, Harris M.I., and Hamman R., 
Eds. GPO, 1985. 

NHANES II, Harris, MI: National Diabetes Data Group, unpublished data. 

Bennett P: Increasing Prevalence of Diabetes in American Indians. In: 
Diabetes 1979. Excerpta Medica. 

National Diabetes Advisory Board, 1985. Annual Report, NIH Publication 
No. 85-1587, May 1985. 



292 



Table 6.1 
HOW THE EFFICACY OF A DIABETES PATIENT EDUCATION PROGRAM CAN BE MEASURED* 

By demonstrating during valid sequential audits that sorae, and preferably 
all, of the following occur: 

1. Decreased sick days. 

2. Decreased days of hospitalization. 

3. Decreased morbidity (diabetic acidosis, amputations, other). 

4. Significant decrease in weight and plasma glucose level in those 
with NIDDM. 

5. Significant decrease in plasma glucose level in those with IDDM. 

6. Decreased costs of evaluation, education, therapy, and followup. 

7. Decreased mortality (increased duration of life). 

8. Improved quality of life (better physical performance, less dis- 
ability and pain, and better mental outlook). 

*The efficacy of the Memphis and Atlanta programs was evaluated as follows: 

For 1, 2, 3, and 6, both were efficacious. 

For 4, weight decreased significantly (more in Atlanta), but mean group 
plasma glucose did not change over a 10-year followup period. 

For 5, there was not a significant decrease in group mean plasma glucose 
levels over a lO-year followup period. 

For 7, since no mortality audit data are available for the period prior 
to initiation of either program, it is not possible to determine whether 
mortality rates changed as a result of the programs. Standard Mortality 
Rates (SMR's) in the programs during a lO-year followup were almost 
identical. 

For 8, audit data are not sufficient to give a definitive answer, but 
numerous patient interviews strongly suggest that quality of life 
improved as a result of the programs. 



293 



Diabetes 



The Effective Approach 
and Management of 
Diabetes In Black and 
Other Minority Groups 



John K. Davidson, M.D., Pli.D. 

Professor of Medicine 

Emory University School of Medicine 

Director, Diabetes Unit 

Grady Memorial Hospital 

Atlanta, Georgia 



Introduction : 

In 1980, the estimated number of prevalence cases of IDDM was 435,000 
and of NIDDM was 5,069,000; the estimated number of incidence cases of GDM 
was 86,000. The American Diabetes Association has estimated that there are 
about 5,000,000 additional cases of undiagnosed NIDDM. If this estimate is 
correct, about 10.6 million Americans or 4.5% of the U.S. population has 
diabetes at the present time. 

Four American minority groups (blacks , Hispanics , American Indians , and 
Japanese Americans are at increased risk for the development of NIDDM, but 
not for IDDM, (Table 1). 

These minority groups as a general rule have not had optimal access to 
continuing quality medical care in the past. As a result, over the last 
half-century, they have accumulated a heavy burden of chronic disease 
(diabetes, hypertension, obesity, and their complications) which still 
adversely affects their health status . This in turn is reflected in 
increasing diabetes-related mortality, morbidity, and costs during the last 
twenty years. That there were serious deficiencies in patient and_ . 
professional knowledge of .diabetes was, noted as early, as 1967 ' ' . 
Also in the 1960s, Miller , Runyan , and Davidson started collecting 
data on Hispanics (Mexican-Americans, Los Angeles) and black Americans 
(Memphis, Atlanta), which proved that continuing access to quality care 
could improve outcomes, decrease hospitalizations, and save money. In the 
1970s, epidemiologic studies have been carried out in the Pima Indians in 
Arizona (Bennett), and five demonstration projects on American Indian 
reservations scattered throughout the USA (Ghodes), have been implemented 
in order to improve the quality of care for native Americans , who bear the 
greatest burden of diabetes of all minority groups . 

The Diabetes Law (FL 93-354, 1974) provided funding for 8 Diabetes 
Research and Training Centers (DRTCs), for 20 Centers for Disease Control 
(CDC) administered state diabetes control programs (DCPs), and for National 
Diabetes Advisory Board (NDAB) activities . NDAB has published guidelines 
for institutions and professionals who want to provide quality patient 
education for those with diabetes . 

The American Diabetes Association, the CDC, and the NDAB sponsored a 
conference on Financing Quality Patient Education for those with Diabetes 
in October 1984 (Conference on Financing Quality Health Care for Persons 
with Diabetes, Oct. 22-24, 1984, Airlie House, Airlie Viginia) . The 
Carter Center sponsored a conference in November 1984 designed to formulate 
a strategy to close the gap between the quality of optimal care and the 
quality of care available to those with diabetes and other health problems 
in 1984. (See Reference 9.) 

Many unsatisfactory treatment outcomes in patients with diabetes, 
especially in those who are members of minority groups, could have been 
avoided or blunted by programs that emphasized and implemented early 
diabetes detection and optimal patient evaluation, education, and 
continuing followup treatment by qualified professionals operating as a 
team (MD, RN, RD, DPM) . 



297 



The 15-year accumulated and continuing experiences of the Memphis 
(Runyan) and Atlanta (Davidson) groups^ "''''' -^ with 
predominately black Americans , largely medically indigent , will be related 
and used as a basis for recommending action to replace the widely-practiced 
contemporary crisis-oriented medical care system for those with diabetes by 
a prevention-oriented care system which emphasizes the importance of early 
diagnosis, optimal medical evaluation, patient education, and access to 
continuing care by a team (MD, RN, RD, DPM, etc.) of adequately trained 
professionals. All minority groups would benefit from such a program in 
that improved health care at lower cost would be available to them. Such a 
program, once in place, could be expanded to include all Americans. 

(9) 
Epidemiology 

The prevalence and relative risk, of developing diabetes in whites, 
blacks, Hispanics, native American (Pima) Indians, and Japanese Americans 
is shown in Table 1. Most of the increased risk is related to the 
increased prevalence of obesity in minority groups in the USA 

The estmated incidence, prevalence, and deaths from IDDM and NIDDM are 
shown in Table 2, and the estimated incidence and prevalence cases of 
complications of diabetes are shown in Table 3. The incidence by age and 
sex is shown in Table 4, and the number of cases by age, race, and sex are 
shown in Table 5 . The prevalence by age , race , and sex is shown in Table 
6. The age-, race-, and sex-specific death rates calculated from 
underlying causes of death data and from multiple causes of death data are 
shown in Table 7 and Table 8 respectively. In each table, it is obvious 
that races other than white, bear a greater burden, and the females of 
other races bear the greatest burden of all. 

Table 9 summarizes the risk factors for diabetes . Table 10 summarizes 
the annual incidence of diabetic ketoacidosis and number of 
hospitalizations (74,961) for same. Table 11 summarizes the incidence of 
blindness end-stage renal disease, and amputation (USA, 1978). Table 12 
shows the estimated number of doctor visits. Table 13 shows the number of 
hospital days due to a first-listed diagnosis of diabetes, and Table 14 
shows the number of hospital days with diabetes as any of seven discharge 
diagnoses. Table 15 shows the direct costs of diabetes, with over 80% of 
the total costs being due to hospitalization. Table 16 shows the indirect 
costs in person-years lost, and Table 17 shows the years of life lost 
before age 65 years because of diabetes as an underlying cause of death. 
Table 18 shows the years of life lost before age 65 years because of 
diabetes as an underlying or contributing cause of death by age, race, and 
sex. 

Pathphysiology ; 

The pathophysiology of NIDDM is closely linked to obesity (> 20% excess 
body weight) and overweight (1-20% excess body weight) 
Proposed Strategy for Developing a Cost-Ef fective Preventive and 
Treatment Program for Diabetes and Its Complications 

See Table 20 for a summary of proposed major interventions and of their 
potential impact on diabetes mellitus and its complications. 



298 



The objective of a prevention-oriented approach to diabt^tes mellitus 
are noted in Table 19. It is estimated that a maximally effective primary 
prevention program could prevent >70% of cases of NIDDM now (see Table 20), 
that secondary prevention could delay the appearance of or prevent many of 
the acute and chronic complications of the established disease, and that 
tertiary prevention could diminish mortality and morbidity caused by the 
acute and chronic complications (Table 20) . 

The successful implementation nationwide of such a program for American 
minority groups will place special responsibilities on professionals and 
patients (Table 21), and will require careful sequential auditing of the 
effects of professional-patient interactions, (including professional 
competence and knowledge, and patient education), intervention therapies 
(and level of patient adherence) , and of the natural history of diabetes as 
related to mortality, morbidity, and costs (Table 22). 

In many institutions during the last half century, physician training 
has been carried out in a crisis-oriented setting. In a crisis-oriented- 
acute-disease environment, it is not possible to deliver comprehensive 
continuing primary care and patient education for individuals who have a 
chronic disease. The numbers and the quality of training of physicians 
available to evaluate, educate, treat, and follow the large numbers of 
patients with chronic diseases (diabetes, hypertension, asthma, heart 
disease, brain and psychiatric disorders, arthritis, etc.) are still, in 
general, inadequate to cope with problems of such magnitude. 

Three diabetes care programs that have served primarily minority groups 
have been developed during the last twenty years (Los Angeles County 
Hospital 1964-1980, Memphis City Hospital 1962-present , Atlanta Grady 
Memorial Hospital 1968-present) . The Los Angeles program served many 
Hispanic (Mexican) Americans from 1964-1980 . Patients had continuing 
access to specially trained nurses (telephone hot line, clinic dropin) who 
were backed by physicians. By using out patient care to prevent or delay 
the development and progression of acute and chronic complications of 
diabetes to the point that necessitated hospitalization, the program was 
impressively effective. 

More than 80% of the individuals served by the Memphis and Atlanta 
programs are American blacks. In 1962, in Memphis, problems in providing 
care for those with a chronic disease plus a public health screening 
program for undiagnosed diabetes prompted Runyan and his colleagues to plan 
and initiate the Memphis Chronic Disease program. As part of this program 
the talents of specially trained nurses, primarily from the public health 
sector, were mobilized to assist physicians in an organized program 
designed to provide continuing access to care for individuals with chronic 
disease(s). Planning for the Atlanta continuing care program for those 
with diabetes at Grady Memorial Hospital was initiated in 1968, and again 
specially trained nurses played a pivotal role in the program's 
development. Both programs have collected and evaluated process of care 
and outcome data for more than fifteen years, and the experiences of both 
programs hav5^e^Q,f^p^5t^^^^^ series of 
publications '♦'''»». 

Recently federally funded diabetes control programs (DCPs) administered 

299 



by the Centers for Disease Control through twenty state health departments 
have been initiated, the European Diabetes Education Study Group has 
expanded its activities ' , and proprietary hospitals and clinics in the 
USA providing comprehensive diabetes evaluation, education, and treatment 
have been opened. Thus the concepts that were spawned more than fifteen 
years ago, and that have been nurtured since that time in the Memphis and 
Atlanta programs , have become benchmarks that are now regarded as the 
initiators of more treatment-effective and more cost-effective methods for 
the delivery of medical care to those with diabetes . 

Both programs carried out a prospective "needs assessment" to identify 
its problems and to define its aims and goals. The initial problems 
identified in each program are listed in Table 23. Both programs noted 
important existing gaps in services that were then available to persons 
with diabetes. Based on these assessments, strategies were developed to 
expand personnel and facilities (Figure 1) that could lead to a resolution 
of the problems (Table 24) by providing services for early detection, 
patient education, optimal therapy, and continuing followup care (the 
prevention-oriented approach) . The hypothesis that was tested and found to 
be valid in both programs was: a prevention-oriented approach to diabetes 
will be more therapeutically-ef fective and more cost-effective than a 
crisis-oreinted approach . 

Table 25 compares processes of care and audited outcomes in the two 
programs. Both used defined published policies and procedures, which 
included collection of a complete data base, evaluation, education, and 
continuing access to followup care. The specially trained nurse was the 
primary contact professional in each program. The patient had continuing 
access to the nurse and the nurse had continuous backup by a physician and 
dietitian in both programs, and to a podiatrist in the Atlanta program. 

Diabetic ketoacidosis-infections decreased 60% in Memphis and severe 
diabetic ketoacidosis decreased 78% in Atlanta. Amputations decreased 68% 
in Memphis and 50% in Atlanta (Table 25). These two audited outcomes alone 
accounted for a marked decrease in days of hospitalization in both 
programs . 

Processes of care differed in the two programs (Table 25) . Memphis 
used diet therapy alone (25%), diet and oral agents (50%), and insulin 
(25%), while Atlanta used short-term fasts and diet alone (81%) or diet and 
insulin (19%), and did not use sulfonylureas or phenformin after 1970. 
Patients in Atlanta lost significantly more weight (Table 25). Plasma 
glucose levels in both programs from 1970 to 1979 decreased in more than 
70% of those participating in both programs, but because plasma glucose 
levels in the others rose, there was no significant change in the mean 
plasma glucose levels in either program over a 10 year followup period 
(Table 25). 

Mortality ratios which antedate the programs are not available, so it 
is not possible to determine whether the programs decreased mortality. 
After the programs were initiated, the mortality ratios in the two programs 
were almost identical (Table 26). 

The Atlanta program has saved Grady Memorial Hospital over eleven 



300 



million dollars (Table 27). The Memphis program has decreased 
hospitalizations, diabetic ketoacidosis, and amputations, and as a result 
had a similar level of cost-effectiveness. 

Thus, in the 1970s, these two programs set precedents for the planning 
and implementation of diabetes care and patient education programs. Also, 
they became the models that were used by the NDAB to establish standards 
for national diabetes education programs. When subjected to eight 
categories of evaluation, the Memphis and Atlanta programs have been 
efficacious in four, partially efficacious in one, probably efficacious in 
one, and not efficacious in one. Efficacy could not be determined in one 
(Table 28). 

It is now reasonably certain that patient education as an isolated 
event (several versions) is not efficacious, and that patient education as 
an integral component of continuing optimal care (several versions) by a 
team (MD, RN, RD, DPM, etc.) is efficacious. 

Medicare, Medicaid, Blue-Cross Blue Sheild, and all private health 
insurance companies started paying for patient education as an integral 
part of continuing care at the inception (1971) of the Grady Memorial 
Hospital Diabetes Unit Program, and they are still paying for the care and 
patient education provided by the program in 1984 (Table 27). 

Some details of the decrease in DKA incidence and amputation incidence 
are shown in Tables 29-A and 29-B and Tables 30-A and 30-B. 

The 1978 costs and effectiveness of the expanded nutrition care program 
designed to produce weight loss in those with NIDDM at Grady Memorial 
Hospital are shown in Tables 31, 32, 33, and 34, and the savings from not 
using sulfonylureas and from using less insulin are shown in Tables 35 and 
36. The 1978 costs of initial and followup nursing care are shown in Table 
37. 

Although those who are developing new programs can benefit from the 
experiences of the Memphis and Atlanta programs, each new program must 
carry out a needs assessment of the population(s) to be served before 
committing facilities and personnel. Strategies, facilities, and processes 
of care then can be formulated , and outcomes can be audited and evaluated 
as noted in Figure 1 . 

Since NIDDM is very common and is closely correlated with overweight, 
it is important that intervention strategies for its treatment be carefully 
planned and implemented. National strategies that may be useful are listed 
in Table 38, and some of the barriers to the implementation of those 
strategies are listed in Table 39. 

Since the American Diabetes Association has estimated that there are 
five million Americans with undiagnosed NIDDM, a sensitive screening method 
has been developed. The random quantitative urine glucose method (RUG) has 
a sensitivity of 100% and a specificity of 99.3% in detecting those with 
undiagnosed NIDDM. See Figure 2, Figure 3, and Table 40. 



301 



REFERENCES 

1. Etzwiler FD: Who's teaching the diabetic? Diabetes 16:111-117, 1967. 

2. Watkins JD, Williams TF, Martin DA, Hogen MD, Anderson E: The 
clinical picture of diabetic control studied in four settings. Am J 
Public Health 57:452- , 1967. 

3. Williams TF, Anderson E, Watkins JD, Coyler: (Title) J Am Diet Assoc 
51:19- , 1967. 

4. Miller LV, Goldstein J (1972): More efficient care of diabetic 
patients in the county-hospital setting. N Engl J Med, 285, 1388. 

5. Runyan JW Jr., Vander Zwaag R, Joyner MB, et al: The Memphis diabetes 
continuing care program. Diabetes Care 3:382-386, 1980. 

6. Davidson JK: B3ucating diabetic patients about diet therapy, i^^^ 
Diabetes Fed Bull, 20:1, 1975. 

7. Knowler WC, Bennett PH, Pettitt DJ, Savage PJ: (t>esity and diabetes 
in Pima Indians: The effects of parental diabetes on the relationship 
of obesity and the incidence of diabetes, in (Melish JS, Hanna J, 
Baba S Eds) , Genetic environmental interaction in diabetes mellitus, 
pp 95-100, Excerpta Msdica, Amsterdam, 1982. 

8. Conference on Financing Quality Health Care for Persons with 
Diabetes, Oct. 22-24, 1984, Airlie House, Airlie, Virginia 

9. Herman WH, Teutsch SM, Geiss LS: Carter Center Health Policy Project 
- Closing the Gap. Health Problan: Diabetes Mellitus, Nov. 26-28, 
1984, Atlanta, Ga. 



10. Davidson JK: The Grady Memorial Hospital diabetes unit ambulatory 
care program. (Bds. Assal J PH, Assal M, Berger N, Canivet Gay & J) 
pp 34:286-297 in Excerpta Medica, ;>msterdam-Ox ford-Princeton, 1982. 

11. Davidson JK: The Grady Manorial Hospital diabetes programme in 
Diabetes in Epidemiological Perspective. JI Mann, K Pyorala, A 
Teuscher, (Eds.), pp 332-341. Churchill Livingstone, Edinburgh 
London, Melbourne, and New York, 1983. 

12. Vander Zwagg R, Runyan JW Jr., Davidson JK, Delcher HK, Mainzer I, 
Baggett HW: A Cohort Study of Mortality in Two Clinic Populations of 
Patients with Diabetes Mellitus. Diabetes Care 6:341-346, 1983. 

13. Davidson JK, Vander Zwaag R, Cox CL, Delcher HK, Mainzer I, Baggett 
H, Runyan JW: The Memphis and Atlanta Continuing Care Programs for 
Diabetes. II. Comparative Analyses of Demographic Characteristics, 
Treatment Methods, and Outcomes over a 9-10 year Follow-up Period. 
Diabetes Care 7:25-31, 1984. 

14. Davidson JK, Runyan JW: The efficacy of patient education in the 
Memphis and Atlanta Continuing Care Programs for diabetes. Submitted 
Diabetes Care for publication. Diabetes Care, 1984. 



303 



15. Davidson JD: Non-Insulin Dependent Diabetes Mellitus. (ed) Davidson 
JK, in Clinical Diabetes Mellitus:A Problem-Oriented approach. 
Thieme-Stratton, Inc. N.Y., N.Y. to be published 1985. 

16. Mulhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L, 
Kunz A, Schernthaner G, Scholz V, Voss HE: Bicentic evaluation of a 
teaching and treatment progranme for type I diabetic patients. 
Improvement of metabolic control and other measures of diabetes care 
for up to 22 months. Diabetologia 25:470-476, 1983. 



304 



TABLES AND FIGURES 



TABLES 

Table 1: Age adjusted prevalences and relative risks of diabetes by type 
of diabetes and race — United States. 

Table 2: Estimated number of incident and prevalent cases of diabetes 
and deaths of people with diabetes — United States, 1980. 

Table 3: Estimated numbers of incident and prevalent cases of complications 
of diabetes — United States, 1980. 

Table 4: Incidence of diabetes per 100,000 by age and sex — United States, 
1978. 

Table 5: Numbers of cases of diabetes in thousands by age, race, and 
sex — United States, 1978. 

Table 6: Prevalence of diabetes per 100,000 by age, race, and sex — United 
States, 1978. 

Table 7: Age-, race-, and sex-specific death rates per 100,000 calculated 
from underlying cause of death data — United States, 1980. 

Table 8: Age-, race-, and sex-specific death rates per 100,000 from multiple 
cause of death data — United States, 1979. 

Table 9: Summary of risk factors for complications of diabetes. 

Table 10: Numbers of hospitalizations and annual incidence of diabetic 
ketoacidosis per 1000 by age and sex — United States, 1980. 

Table 11: Incidence of blindness, end-stage renal disease and amputation, 
by diabetes status and age — United States, 1978. 

Table 12: Estimated numbers of doctor visits in thousands. Diabetes as 

any one of three physician's diagnoses; by age, race, and sex — 
United States, 1980. 

Table 13: Numbers of hospital days in thousands. Diabetes as first-listed 
discharge diagnoses; by age, race, and sex — United States, 1980. 

Table 14: Numbers of hospital days in thousands. Diabetes as any of seven 
discharge diagnoses; by age, race, and sex — United States, 1980. 

Table 15: Estimated direct costs of diabetes mellitus in millions of dollars — 
United States, 1980. 



305 



Table 16: Estimated indirect costs of diabetes mellitus in thousands of 
person-years lost — United states, 1980. 

Table 17: Years of life lost before age 65. Diabetes as underlying cause 
of death; by age, race, and sex — United States, 1980. 

Table 18: Years of life lost before age 65. Diabetes as underlying cause 
or contributing cause of death; by age, race, and sex — United 
States, 1979. 

Table 19: The objectives of a prevention-oriented approach to diabetes mellitus. 

Table 20: Major interventions and potential impact (adapted and recalculated 
from data in reference 9). 

Table 21: Professional's obligations to patients. 
Patient's obligations to themselves. 

Table 22: Auditing the effects of the natural history of intervention therapy, 
and of professional-patient interactions on outcomes. 

Table 23: Initial problems. 

Table 24: Strategy and structure personnel, facilities for the resolution 
of the problems noted in Table 23. 

Table 25: Processes of care and audited outcomes. 

Table 26: Standarized mortality ratios (SMRs). 

Table 27: Costs avoided, third party payments for ambulatory care, ambulatory 
care expenditures, and cost-effectiveness of the Grady Memorial 
Hospital diabetes unit program, in dollars saved. 

Table 28: How can the efficacy of the diabetes patient education and 
continuing care programs be measured? 

Table 29A: Severe diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar 
state (HHS) from 1969, 1974-1980 and total of mild, moderate, 
and severe diabetic ketoacidosis (DKA) and hyperglycemic 
hyperosmolar states (HHS) from 1974-1980 at Grady Memorial 
Hospital. 

Table 29B: Some demographic and other characteristics of 96 individuals 

admitted to Grady Memorial Hospital in 1978 with severe diabetic 
ketoacidosis (C02content < 10 mEQ/1) and/or with a hyperglycemic 
hyperosmolar state (serum osmolality > 350 mOSm). 

Table 30A: Lower extremity amputations in patients with diabetes mellitus 
at Grady Memorial Hospital 1973-1980. 



306 



Table 30B: Some demographic and other characteristics of 68 Individuals 
with diabetes mellltus who had lower extremity amputations 
at Grady Memorial Hospital In 1978. 

Table 31: Record of dietitian's time In diabetes unit, January 1969 
through 1979. 

Table 32: Total cost of expanded nutritional care program for 8 years 
(1971-1978) and for 1978. 

Table 33: Approximate cost of expanded nutritional care program per 
patient visit, 1978. 

Table 34: Weight history of 127 patients with complete follow-up, 
1971-1977. 

Table 35: Projected savings due to changes In medication and expanded 
nutritional care program. 

Table 36: Use and cost of Insulin, 1969-1978. 

Table 37: Cost of nursing care In Grady Memorial Hospital diabetes unit 
In 1978. 

Table 38: Strategies that may be useful In blunting the effects of NIDDM 
In American minority groups. 

Table 39: Barriers to Implementing the strategies proposed In Table 38. 

Table 40: Sequential testing routine to detect and diagnose diabetes In 
the nonpregnant Individual. 



FIGURES 
Figure 1 : 

Figure 2: 

Figure 3: 



Methods for developing, monitoring, and evaluating a health 
care delivery system. 

Distribution of random (undiluted) urine glucose levels in 1952 
screenees. 

Comparison of random urine glucose levels and fasting plasma 
glucose levels in those with renal hyperglucosurla and in those 
with diabetes mellltus. 



307 



TABLE 1 



AGE ADJUSTED PREVALENCES AND RELATIVE RISKS OF DIABETES 
BY TYPE OF DIABETES AND RACE 
UNITED STATES 



Type I Diabetes 

Prevalence per 
100,000 

Relative Risk* 



White 



16rf 



1.0 



Black Hispanic 



130' 



0.8 



150^ 



0.9 



Native 
American 
(Pima) 



Japanese 
American 



<1.0' 



<1.0' 



Type II Diabetes 



Prevalence per 
100,000 


2,300? 


Relative Risk* 


1.0 



2,906^ 7,200* 24,800' 
1.3 3.1 10.8 



1.4' 



* Risk compared to US vhite population. 



Sources: 



LaPorte RE: The prevalence of insulin-dependent diabetes mellitus. In 

Diabetes Data- Compiled 1983, National Diabetes Data Group, NIH, in press. 

Young W, Murphy S, Marcus P, Hamman R: Prevalence of diabetes and incidence 
of related acute complications in Denver area school-age children. In 
Proceedings of the 6th Annual CDC Diabetes Control Conference, Centers for 
Disease Control, 1983. 

Sieves ML, Fisher JR: Diabetes in Native Americans. In Diabetes Data- 
Compiled 1983, National Diabetes Data Group, NIH, in press. 

Fujimoto vnf: Diabetes in Asian Americans. In Diabetes Data- Compiled 
1983, National Diabetes Data Group, NIH, in press. 

Harris M: The prevalence of noninsul in-dependent diabetes mellitus. In 
Diabetes Data- Compiled 1983, National Diabetes Data Group, NIH, in press. 

Stern MP: Diabetes in Hispanics. In Diabetes Data- Compiled 
1983, National Diabetes Data Group, NIH, in press. 

Knowler WC, Pettitt OJ, Savage PJ, Bennett PH: Diabetes incidence in Pima 
Indians: Contributions of obesity and parental diabetes. 
Am J. Epidemiol 113:144-156, 1981. 

Bennett CG, Tokuyama GH, Bruyers PT: Health of Japanese Americans in 
Hawaii. Public Health Reports 78:753-62, 1963. 



308 



TABLE 2 



ESTIMATED NUMBER OF INCIDENT AND PREVALENT CASES OF DIABETES 

AND DEATHS OF PEOPLE WITH DIABETES 

UNITED STATES, 1980 



Incident 
Cases 



Prevalent 
Cases 



Deaths 



Type I Diabetes 
Mellitus 

Type II Diabetes 
Mellitus 

Gestational 
Diabetes Mellitus 



19,000 

586,000 

86,000 



435,000 



5,069,000 



19,000 



304,000 



309 



TABLE 3 



ESTIMATED NUMBERS OF INCIDENT AND PREVALENT CASES 

OF COMPLICATIONS OF DIABETES 

UNITED STATES, 1980 



Incident Cases 



Prevalent Cases 



Diabetic Ketoacidosis 



75,000 



Serious 




Congenital Malformations 


850 


Stroke 


23,000 


Coronary Heart Disease 


85,000 


Peripheral Vascular 




Disease 


A1,000 


Blindness 


5,800 


End-Stage Renal 




Disease 


4,000 


Amputation 


31,000 



320,000 
650,000 

A97,000 
40,000 

7,600 
71,000 



310 



TABLE 4 



INCIDENCE OF DIABETES PER 100,000 

BY AGE AND SEX 

UNITED STATES, 1978 



Age Men Women Total 



<25 


— 


*29 


*14 


25-44 


233 


153 


192 


45 - 54 


*189 


724 


466 


55 - 64 


*332 


955 


661 


65 + 


859 


941 


907 



TOTAL 191 337 267 



* Figure does not meet standards of reliability or precision. 

Source: National Diabetes Data Group, NIH, from the 
National Health Interview Survey, 1978. 



311 



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321 



TABLE 15 

ESTIMATED DIRECT COSTS OF DIABETES MELLITUS IN i MILLIONS 

UNITED STATES, 1980 



i Million 

Physician Office Visits' < 652 

Hospitalization^ $6,157 

Nursing Home Care i 663 

Insulin and Oral Hypoglycemic 

Agents'* i 380 

TOTAL $7,852 

Sources: 

National Center for Health Statistics: National Ambulatory Medical 
Care Survey, public use data tapes, 1980. 

National Center for Health Statistics: Public use National Hospital 
Discharge Survey data tapes, 1980. 

National Center for Health Statistics: 1977 National Nursing Home 
Survey. Current Population Reports No 917:25, 1982. 

Van Nostrand JF: Diabetes and long term care. In Diabetes Data- 
Compiled 1983, National Diabetes Data Group, NIH, in press. 

Metropolitan Life Insurance Company Statistical Bureau: Estimates 
cited by Entmacher PS: The economic impact of diabetes. In 
Diabetes Data-Compiled 1983, National Diabetes Data Group, NIH, 
in press. 
National Center for Health Statistics: Medication therapy in office 
visits for selected diagnoses: The National Ambulatory Medical 
Care Survey, United States, 1980. Vital and Health Statistics. 
Series 13-No. 71. DHHS Pub. No. (PHS) 83-1732. Public Health 
Service. U.S. Government Printing Office, Washington, D.C., 1983. 



322 



TABLE 16 

ESTIMATED INDIRECT COSTS OF DIABETES MELLITUS 

IN THOUSANDS OF PERSON-YEARS LOST, 

UNITED STATES, 1980 



Disability Thousands of Person-Years Lost 
Employed persons with DM* 37.5 

Homemakers with Dif 53.0 

Unemployed because of DM* 116.3 

Mortality 
Premature mortality' 1,450.0 



Sources: 



Metropolitan Life Insurance Company Statistical Bureau: Estimates 
cited by Entmacher PS: The economic impact of diabetes. In 
Diabetes Data-Compiled 1983, National Diabetes Data Group, NIH, 
in press. 

Herman WH, Sinnock P, Brenner E, .et al: An epidemiologic model for 

diabetes mellitus. Incidence, prevalence, and mortality. Diabetes 
Care, in press, 1984. 
National Center for Health Statistics: Public use mortality data 
tapes, 1980. 



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325 



Table 19 
The objectives of a prevention-oriented approach to diabetes mellitus 



Prevention-oriented 



1. 



2. 



3. 



Primary prevention 
(Applied to the general 
population, i.e. 240 million 
ftnericans) 



Secondary prevention (Applied 
when diabetes mellitus is 
diagnosed; an estimated 6.1 
million Americans know they 
have diabetes, estimated 5 
million have diabetes but do 
not know it) 



Tertiary prevention (Applied 
when acute or chronic complica- 
tions of diabetes mellitus are 
detected; an estimated 5 million 
Americans have, or will have, 
one or more of these complica- 
tions) 



Objectives 

To prevent the appearance of hyper- 
glycemia throughout a lifetime by (1) 
avoiding or "curing" excess body weight 
and (2) preventing viral-induced (?) 
and other beta-cell damage (research 
underway) 

To prevent the acute complications and 
to prevent or delay the appearance of 
the chronic complications of diabetes 
mellitus. These objectives may be 
accomplished by early detection of 
randan glucosuria and hyperglycemia and 
by appropriate education, therapy 
(diet, exercise, insulin if needed) and 
follow-up to attain and maintain ideal 
body weight and normoglycemia or near- 
normoglycemia 

To decrease mortality and morbidity 
resulting from acute and chronic 
complications of diabetes mellitus by 
prevention of or by early detection 
and prompt and appropriate therapy of 
the complications. 



326 



TABLE 20 

MAJOR INTERVENTIONS AND POTENTIAL IMPACT 
(ADAPTED AND RECALCULATED FROM DATA IN REFERENCE 9) 



PROBLEM 
IDDM 



INTERVENTION (S) 



% PREVENTABLE PREVENTABLE CASES/YEAR 



NIDDM 



(DM 



WEIGHT CONTROL 



WEIGHT CONTROL 



>70% 



>50% 



410,000 
43,000 



DKA 



ED, HBGM, COOTINUING 
ACCESS TO OPT. CARE 



>70% 



>52,000 



CONG. MALF. ED, HBO^, ACCESS 



>70% 



500 



STROKE 



CHD 



HBP CONTROL 

HBP & LIPID CONTROL 
NO SMOKING 



85% 



45% 



19,000 
38,000 



PVD 



HBP & LIPID CONTROL 
NO SMOKING 



60% 



24,000 



BLINDNESS 



ESRD 



AMPUTATIONS 



LASER 



HBP CONTROL 



POD. CARE, HBP AND 

PG CONTROL, NO SMOKING 



50% 



50% 



50% 



2,900 

2,000 

15,000 



327 



TABLE 21 

Professional's obligations to patients 

Give complete and accurate information reference the natural history of 
diabetes mellitus and its complications and reference the benefits, 
risks and costs of available intervention therapeutic modalities 



Patients' obligations to themselves 

Once patients become thoroughly knowledgable about diabetes and its 
natural history, their freedom of choice permits them to respond to 
professional recotmendations in a self-determined way. This in turn 
determines whether a patient will adhere or not adhere to a prescribed 
routine, and for how long. Continuing access to quality care can 
reinforce adherence, and it may determine whether a patient will be 
rewarded by adherence, or penalized by non-adherence, to prescribed 
routines. 



328 



TABLE 22 

Auditing the effects of the natural history, of intervention 
therapy, and of professional-patient interactions on outcomes 



Aix3it by appropriate (yearly) sequential measurements of outcomes as 
affected by the natural history of the disease (compare to a matched 
population of non-diabetic controls) and by the effects of intervention 
therapy (therapies) and adherence or non-adherence to prescribed 
routines in a defined population of patients. Ideally, all 
complications (diabetic ketoacidosis, hyperosmolar hyperglycemic state, 
retinopathy, nephropathy, arteriopathy and neuropathy) and associated 
problems should be audited. Practically, some problems (i.e. 
ketoacidosis and amputations) are easier to audit sequentially than are 
others. In each program, the eventual aim should be to measure 
outcomes (mortality, morbidity) in terms of the natural history of 
diabetes as influenced by various types of available intervention 
therapy (benefits, risks, costs) 



329 



TABLE 23 



Initial Problems 



Memphis 



Atlanta (GMH) 



Problems 1962 - 1963 



Problems 1968 - 1969 



1. The city of Memphis Hospital (CMH) 
Department of Medicine Outpatient 
Department (DPD), J.W. Runyan Director, 
had inadequate personnel and facilities 
to adequately cope with an overload of 
patients with chronic diseases (85% of 
whom had diabetes, and/or hypertension, 
and/or cardiac disease) . 

2 . The overload of patients was made even 
more serious by an effective screening 
program for diabetes carried out by the 
Shelby County (Tenn.) Health Department 
with referral of positive screenees to 
the CMH-OPD. 

3. An inadequate number of physicians in the 
CMH-OPD resulted in crisis-oriented care, 
and this in turn resulted In frequent 
preventable hospitalizations, episodes of 
diabetic ketoacidosis, and amputations. 



1. Limited access to Diabetes Clinic (DC) 
(4650 visits per year, 1967-1968) for 
estimated 12,950 patients with diabetes In 
the GMH served population of approximately 
350,000. 

2. Preferential use of sulfonylureas, 
phenformin, or insulin even in the obese. 

3. Facilities: Two 3-hr. clinics a week in 
Medical Clinic area (about 2,000 sq. ft.). 

4. Personnel: 4 to 6 interns and residents 
rotating every one to six months, 2 staff 
nurses, 3 part-time Medical Clinic 
registered dietitians (1.96 R.D. 
work-years instructing diabetic patients), 
1 faculty diabetologist plus clinical 
faculty, house staff, and students. 

5. Equipment: Limited to examinaing 
instruments. No stat venous plasma 
glucose levels available. 

6. Supplies: Cllnitest tabs (urine sugar); 
Acetest tabs (urine acetone); mimeographed 
diet sheets. 

7. Diabetes Clinic: 

a. Source-oriented; medical records (50Z 
illegible). 

b. Physician averaged 10 min. with each 
patient, tried "to control urine sugar" 
with oral agents or insulin. No audits 
on plasma glucose levels available. 

c. Dietary prescription (if written) 
frequently inappropriate; follow-up 
inadequate. 

d. Staff nurse gave instruction on insulin 
administration and urine testing. 

e. No other patient education. 

f . Volunteer podiatrist; insufficient time 
to care for foot ulcers. _ 

8. Hospitalization: Only one third of cases 
of severe diabetic ketoacidosis 

CO <10 mEq per liter) admitted. Hypo- 
glycemic patients seldom admitted. 
Estimated that half of amputations could 
be prevented by appropriate preventive 
foot care. 



330 



TABLE 23 (continued) ^^, ,^„. 

' Atlanta (GMH) 



Problems 1968 - 1969 

9. 502 episodes of severe (CO content <10 
mEq/1) DKA (1969). ^ 

10. 172 lower extremity amputations (1973). 

11. Hospitalizations: Data not available (no 
audits done) . 

12. Essentially no weight loss. 

13. Many patients were lost to followup when 
DC appointments were missed. These 
patients frequently visited the General 
Adult Clinic or the Medical Emergency 
Clinic for refills of oral agent or 
insulin prescriptions, or when acute or 
chronic complications occurred. This 
limited access to care in the DC 
inevitably led to the crisis-oriented 
approach to the disease. Deaths, missed 
work, and patients lost to follow-up were 
not audited. 

14. Hypoglycemia in the Medical Emergency 
Clinic was common, but was not audited. 

15. Deficiencies in structure and process 
were apparent , but could not be corrected 
until resources became available to 
change the strategy, structure, and 
process of care. 



331 



TABLE 24 
Strategy and Structure (Personnel, Facilities) 
for the resolution of the problems noted in Table 23 



Memphis 



Atlanta 



1. 1963 - Chronic Disease Continuing Care 
Program initiated. 

2. 1969 - (April) Program revision 

Current Locations: 
Urban - 11 
County - 5 
Rural - mobile bus > 10 

3. Clinic sessions (1/2 day) > 26/wk. 
Clinic visits > 35,000/yr 

Home visits > 1,500/yr 

Current patients > 8,000 - projected > 

15,000 

Newly referred patients - 150-400/mo 

Missed appointment rate (July-December 

1971) - A. 5% 

4. The Chronic Disease Continuing Care 
Program of Memphis and Shelby County is 
staffed by public health nurses in the 
neighborhood health centers to whom 
patients with chronic diseases are 
referred for continuing followup care, 
evaluation and medication refills. They 
also provide home health care and referral 
for diatetic, social, and rehabilitation 
services. An MD is available for phone 
consultations, and secondary and tertiary 
care are provided in the CMH-OPD, 
emergency ward, or hospital inpatient 
facilities as needed. 

5. As would be expected, diabetes mellitus 
frequently is discovered in this large 
population of chronic disease patients by 
routine testing of the blood sugar. 

6. Of the 3 major categories of chronic 
diseases, the control of the diabetic is 
the most challenging for the nurses. The 
background and training of the nurses , the 
detailed protocols for each disease 
category, and medical backup permit the 
nurse to feel comfortable in managing 

the patient. Diet is stressed and the 
nurses are familiar with the budgetary 
limitations of the patient and his food 
habits. Medications include insulin (NPH 



Diabetes Detection and Control 
Center (DDCC): Immediate appointment 
for problem-oriented data base, 
education, plan of therapy. 



3. 

4. 
5. 



DC: Free access to 
primary care (over 
made 24,993 visits 
telephone calls in 



continuing 
5,000 patients 
and 8,642 
1978). 



Expanded nutritional care program: 
No oral agents; limited use of 
insulin. 

Screening for early detection. 

Facilities: Diabetes Unit open 8 hr. 
a day, five days a week in 10,000 
sq. ft. ambulatory care space (DDCC, 
DC, Podiatry Clinic, Laboratory); 
in-patient medical and surgical beds 
available as needed. 

Personnel: 4 physicians, 12 
registered nurses, 4 registered 
dietitians, one podiatrist, 24 
supporting persons. 

Equipment: One automated and 6 
manual glucose analyzers, examining 
instruments, intelligence terminal 
for computer entry of patient data. 

Supplies: Diabetes Guidebook: Diet 
Section, meals, measuring cups, 
spoons, and ruler, food models, 
posters, audiovisuals. 

DDCC: Patient can be evaluated and 
educated within 24 hr. after 
referral. Using defined policies 
and procedures , a problem-oriented 
data base (subjective, objective, 
assessment) is collected and a plan 
for education, diet, exercise, and 
insulin therapy (if indicated) 
formulated. 






332 



TABLE 24 (continued) 



Memphis 



Atlanta 



and regular), phenformin (control 1978) 
chlorpropamide and tolbutamide and the 
dose of these medications were adjusted 
based upon symptoms, urine tests and/or 
blood sugar levels. The nurse may give 
insulin (NPH and/or regular) to patients 
on diet or oral medications alone, 
temporarily to regain control. Factors 
contributing to poor control, such as 
improper use of medications, emotional 
problems, dietary irregularity and 
infections are searched for and at times 
a home visit has been instructive in 
revealing the problem. 



10. DC: Patients have unlimited access 
to primary care on a continuing 
basis. Panel of 750 patients for 
each of the registered nurses 
(primary contact professionals), 
backed by 4 registered dietitians, 
each of whom provides nutritional 
education and followup for a panel 
of 1500 patients: a podiatrist 
provides foot education, evaluation, 
and care: and 4 physicians provide 
overall supervision and back-up 
care. 

11. Hospitalization: Medical, Surgical, 
Obstetrical Services as needed. One 
diabetes teaching nurse on Medicine 
and one on Surgery audit follow all 
patients with diabetes and arrange 
post-discharge DC or DDCC followup. 
All patients with severe DKA and 
hyperglycemic hyperosmolar comas and 
significant hypoglycemia admitted. 



333 



TABLE 25 
PROCESSES OF CARE AND AUDITED OUTCOMES 



Memphis 



Atlanta 



1. Defined policies and procedures for 
Initial and followup care (See Runyan: 
Primary Care, Harper and Row, 1982). 

2. Evaluation, therapy prescribed CMH-OPD, 
referred for followup by nurse in 
satellite public health clinic. 

3. Use of diet (hypocaloric) to encourage 
weight loss in over-weight individuals 
plus sulfonylurea or insulin if needed 
in the physician's or nurse's judgment. 

4. 1979: 25% on diet alone, 50% on oral 
agents, 25% on insulin. 

Hospital Days per 1000 Patients 



per Year (1975) 












6. 




Study 






Before 


After 


% Change 




5. Diabetes 








All causes 3319 


1680 


-49.4 




Diabetic acid- 






7. 


osis-infections 900 


350 


-61.1 




Peripheral Vascu- 






8. 


lar disease & Am- 








putation 626 


201 
Control 


-67.9 




Before 


After 


% Change 




Diabetes 









All causes 2728 

Diabetic acid- 
osis infections 587 

Peripheral Vascu- 
lar Disease & Am- 
putation 626 



4838 +77.3 
688 +17.2 



201 



-13.1 



Weight Change ; 1970 — > 1979 (Cohort of 

239 patients) 
Diet : 58% 4r , 42% 'f , mean wt . loss 9.41b 
Insulin ; 54% ^ , 46% 'f , mean wt. loss 

2.4 lb 
Oral Agents : 68% ir , 32% t , 

mean wt loss 8.3 lb 



7. Plasma glucose change : 1970 
(Cohort of 239 patients) 
Diet ; 72% 0' , 28% T 
Insulin : 40% ^ , 60% T 
Oral Agents : 83% ^, 17% 1^ 



1979 



1. Defined policies and procedures Policy 
and Procedure Manual Diabetes Unit , 
Grady Memorial Hospital 1978. 

2. Patient Evaluation, Education, Followup 
(DDCC, DC) (12,784 patients from 1/11/71 
through 5/30/84) 

3. Diabetes Clinic (DC) ; 24,993 patient 
visits, 8642 telephone calls (1978) 

4. Aggressive diet therapy (including one 
week total fasts when indicated) for 
NIDDM (Since 1970). 

5. Use of Sulfonylureas and Phenformin 
discontinued (Since 1970). 

6. Use of insulin limited to IDDM, diabetic 
ketoacidosis, hyperglycemic hyperosmolar 
state, and pregnancy (since 1978) 

Audits-Outcomes 



1981; 81% on diet alone, 19% on insulin 

1978: 950 of 12,950 with diabetes 
hospitalized for 10,925 days with 
primary diagnosis of diabetes or one of 
its complications (73/1000, or 0.84 day 
per patient with diabetes. 1422 or 
12,950 with diabetes (110/1000) were 
hospitalized with a secondary diagnosis 
of diabetes 



9. Severe diabetic ketoacidosis : (CO 

content <10 mEq/1) 38.8 episodes/ 1000 
patients (1969), 8.6 episodies/1000 
patients (1978). Down 77.8%. 

10. Amputations ; 13.3/1000 patients 
(1973), 6. 7/1000 patients (1978). Down 
50%. 

11. Weight Change : 1970 — > 1979 (Cohort of 
437 patients) 

Diet : 90% ^ , 10% "t , mean wt loss 20.3 

lb. 

Insulin: 72% X' . 28% f' , mean wt. loss 

11.3 lb. 



334 



TABLE 25 (continued) 
Memphis Atlanta 

1980 - 7 neighborhood health centers and 12. Plasma glucose change : 1970 — > 1979 
20 satellite clinics. Program providing (Cohort of 437 patients) 
care for more than 10,000 patients. Diet: 67% J/ , 33% "T , 

Since beginning of the program, more Insulin : 55% ^^ , 45% T 

than 5000,000 visits to the 
decentralized clinics. 



335 



TABLE 26 



STANDARDIZED MORTALITY RATIOS (SMRs) 
SMRs = 2g|M|D DEATHS* 1969-1971 through 12/31/79 





Overall 


T 




H 


Diet 


E 




R 


Orals 


A 




P 


Insulin 


Y 





Memphis Atlanta 
1.43** 1.41** 

1.06 1.33 

1.52 

1.78 1.62 



Male _ ^, o ^. 1.66 1.54 

Death Ratio 



Female 



*Death primarily related to age (73%) 
and duration of diabetes (15%) 



**Significantly greater than one (P < 0.05) 



336 



TABLE 27 



COSTS AVOIDED, THIRD PARTY PAYMENTS FOR AMBULATORY 
CARE, AMBULATORY CARE EXPENDITURES, 
AND COST-EFFECTIVENESS OF THE GRADY MEMORIAL HOSPITAL 
DIABETES UNIT PROGRAM IN DOLLARS SAVED 



THROUGH APRIL 30, 1984 



Costs Avoided 



(Since 1/1/71) No oral agents $ 649,805 

(Since 1/1/73) Less Insulin 68,176 

(Since 1/1/74) Prevented DKA (2267 cases) 2,945,600 

(Since 1/1/73) Prevented amputations (811) 9,799,720 

TOTAL $ 13,463,301 



3rd Party Payments for Ambulatory Care 5.998,000 

$ 19,461,30 



Total Ambulatory Care Expenditures 7,931,000 



Cost-Effectiveness of Program in Dollars Saved $ 11,530,301 



337 



TABLE 28 



HOW CAN THE EFFICACY OF A DIABETES PATIENT 
EDUCATION AND CONTINUING CARE PROGRAM BE MEASURED?* 



By demonstrating during valid sequential audits that some, and preferably 
all of the following occur: 

1 . Decreased sick days 

2. Decreased days of hospitalization 

3. Decreased morbidity (diabetic acidosis, amputations, other) 

4. Significant decrease In weight and plasma glucose level in those 
with NIDDM 

5. Significant decrease In plasma glucose level In those with IDDM 

6. Decreased costs of evaluation, education, therapy, and followup 

7. Decreased mortality (Increased duration of life) 

8. Improved quality of life (better physical performance, less 
disability and pain, and better mental outlook) 

*The efficacy of the Memphis and Atlanta programs was evaluated as follows: 
For 1, 2, 3, and 6, both were efficacious. 
For 4 weight decreased significantly (more In Atlanta) but mean group 

plasma glucose did not change over a 10 year followup period. 
For 5, there was not a significant decrease In group mean plasma glucose 

levels over a 10 year followup period. 
For 7, since no mortality audit data Is available for the period prior to 

Initiation of either program, it Is not possible to determine whether 

mortality rates changed as a result of the programs. Standard Mortality 

Rates (SMRs) in the programs during a 10 year followup were almost 

Identical (See Table 26) 
For 8, audit data is not sufficient to give a definitive answer, but 

numerous patient Interviews strongly suggest that quality of life 

Improved as a result of the programs . 



338 



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348 



TABLE 37 
COST CF NURSING CARE IN GRADY MEMORIAL HOSPITAL DIABETES UNIT IN 1978 

Initial Visit (DDCC) 

1127 patients, 2 RNs salary $12,000/year = $24,000 
Mean cost per patient = $24,000/1127 patients = $42.55 

Followup visits (DC) 

6000 active patients (750 per RN) , 8 RNs salary $12,000/ year = $96,000 

23,866 followup visits 

2,983 followup visits per RN = 3.98 followup visits per patient 

Cost per followup visit = 96,000/23,866 visits = $4.03 per visit 

Total cost for nursing care for one patient: $4.03 x 3.98 visits per 
patient = $16.04 

Initial and followup visits for one year = $58.59 



349 



TABLE 38 
STRATEGIES THAT MAY BE USEFUL IN BLUNTING THE 
EFFECTS OP NIDDM IN AMERICAN MINORITY GROUPS 

A. Primary Prevention 

1. Attain and maintain ideal body wsight for life 

a. School and company cafeteria caloric labeling and teaching 

b. Portion sizes by age and sex, attuned to individual need 

c. Option of selection of skim milk and low-calorie-density foods 
(vegetables, fruits, lean meat) 

d. Federal and state departments of agriculture to become 
aggressively involved in production, marketing, and advertising 
of foods to the American public. 

e. Involve restaurants, hotels, airlines, and vending machine 
producers in educating the public reference caloric content of 
foods 

f . Insurance companies to reduce premiums to companies whose 
employees are at ideal body weight, and for companies also v^o 
encourage weight loss programs for the overweight employees. 

g. Worksite intervention and behavior modification programs. 

h. Private enterprises are pronoting exercise and diet as 
producing better and more powerful, sexy feelings. 

i. Health maintenance organizations are more prevention oriented 

B. Secondary prevention 

1. Periodic screening for diabetes (See Figure 2, Figure 3) and early 
diagnosis of diabetes (See Table 40) . 

2. ^propriate patient evaluation, education, and followup treatment. 

3. Note microvascular and macrovascular conplications early and treat 
appropriately. 

4. Set criteria for audit of VA, Champus, Medicare, and Medicaid 
payment systems for diabetes patient education, evaluation, and 
followup care. 

5. Set \3p chronic disease monitoring clinics for those with diabetes, 
hypertension, and overweight. 



350 



TABLE 39 
BARRIERS TO IMPLEMENTING THE STRATEGIES PROPOSED IN TABLE 38 

A. Bitrenched U.S.A. Federal and State government policies 

1. Production and marketing of agricultural products make up a major 
part of the American economy and are strongly supported by the 
government . 

2. The federal government is being driven by economic policy, not by 
health policy. 

a. Example ; disposal of surplus foods such as lard and flour to 
reservation Indians and inner city poor who already bear a 
heavy burden of obesity 

b. Example ; refusal of meals-on-wheels administrators to serve 
less than 1500 calories to those v^o are overweight and have 
NIDrai. 

B. Mericans are constantly subjected to advertisements that advocate 
participating in the "good life" which includes much food (calories) , 
alcohol, and tobacco use. 

C. Food labeling has improved but is still inadequate. 

D. There is a general lack of understanding of the principals of good 
nutrition and exercise at all age levels from childhood to old age. 

E. The health care system is fragmented and is incapable at this time of 
providing adequate patient education. There is little concensus 
concerning optimal initial methods of treating NIDCM (seme prefer diet, 
sane prefer oral agents, some prefer insulin). One eminent authority 
has stated that contemporary continuing medical education (CME) is a 
sham dominated by the drug companies. Is that charge true? If it is, 
what can be done to change for the better post-graduate professional 
(particularly physician) education? 



351 



TABLE 40 

SEQUENTIAL TESTING ROUTINE TO DETECT ftND DIAQJOSE DIABETES 

IN THE NONPREGNANT INDIVIDUAL 

Adapted from Chapter 10: Screening for Diabetes Mellitus, 

Clinical Diabetes Mellitus: A Problem Oriented Approach, 

Thieme-Stratton, New York (In Press) 

(1) Quantitative randum urine glucose (RUG) screen: 

(a) If 3-25 mg/dl {^ 97%) ~> STOP. Diabetes has been ruled out. 
Sensitivity in detecting undiagnosed NIDDM = 100% 

(b) If >25 mg/dl, go to (2) iitmediately. Of those >25 mg/dl, -"^ 75% 
have diabetes and *^ 25% have renal hyperglucosuria on followup 
testing. See (2) , (3) , (4) below. 

(2) Random venous plasma glucose: 

(a) If >200 mg/dl and symptomatic, repeat random venous plasma glucose 
and initiate therapy. 

(b) If <200 mg/dl, go to (3) 

(3) Fasting venous plasma glucose: 

(a) Fasting venous If >140 mg/dl x 2 = diabetes mellitus 

(b) If <140 mg/dl, go to (4) 

(4) Glucose tolerance test (diet-prepped, ambulatory, non-medicated): 

(a) Sum of fasting + 1-2-3 hr. post-100 gm glucose load 
>800 mg/dl X 2 = diabetes mellitus 

(b) Sum = 601-800 mg/dl = nondiabetic high normal 

(c) Sum <600 = nondiabetic 

(d) If GTT is non-diabetic (Sum <800 mg/dl) and RUG >25 mg/dl, the 
screenee has random renal hyperglucosuria 



352 



Figure 1 

Methods for Developing, Monitoring, 

and Evaluating a Health Care Delivery System 




353 



Figure 2 

Distribution of random (undiluted) urine glucose levels in 1952 
screenees. 



t40 
X20 

too 

MO 
I60 

t I20 

O 
K 

u too 
§ 

i .o 

eo 

40 
20 

o 



W-V^N^VP**- 



^ 1 I' o'vtim 



* * t \ \ V \ 

URINE GLUCOSE (mg/tfl) 



Abscissa: log scale 

Reproduced with permission from Diabetes 27:811, 1978 



354 



Figure 3 



Comparison of random urine glucose levels and fasting plasma 
glucose levels in those with renal hyperglucosuria and in those 
with diabetes mellitus. 



•00 
•00 

700 

•00 

1 ". 



i 300 



s too 
8 



A Renal Hyperglucosuria 
GTT SUM < eoo mg/Ol 

O Diabetes Meliitua 

FPG < 140 mg/dl. GTT SUM > BOO mg/dl 

• Diabetes Meliilu* 
FPG > 140 mg/tfl 



• • • 



*.•• 



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*'■•"*• • ■ 



10 10 40 to 100 aoo »oo imo smo iomo 
Random Urins Glucose (mg/dl) . . log acslc 



Distribution of random urine glucose (RUG) levels in 95 of 4141 
screenees whose RUG level was >2S mg/dl (abscissa: log scale) 
and comparison to the fasting plasma glucose level (ordinate). 
The highest RUG level in a renal hyperglycosuric was 317 mg/dl, 
all with RUG levels higher than 317 mg/dl had diabetes 
mellitus. The lowest RUG level In those subsequently shown to 
have diabetes mellitus was 26 mg/dl. In the RUG range from 
26-317 mg/dl, there were 27 screenees who had renal 
hyperglucosuria and 22 screenees who had diabetes mellitus (19 
whose FPG was >140 mg/dl, 3 whose FPG was <140 mg/dl and whose 
GTT sum was >800 mg/dl). 

Reproduced with permission from Fed. Proc. 40, 741, 1981. 



355 



Diabetes 



Factors Relating To the 
Increased Prevalence of 
Diabetes In Hispanic 
Americans 




Michael P. Stern, M.D. 

Division of Clinical Epidemiology 
Department of Medicine 
University of Texas Health Science Center 
San Antonio, Texas 



Factors Relating to the Increased Prevalence 
of Diabetes in Hispanic Americans 



I. Introduction 

According to the 1980 census of the U.S. population there are 14.6 million 
individuals of Hispanic origin in the U.S., 8.7 million of whom are Mexican 
Americans, with 2 million being Puerto Rican and 800,000 Cuban. Despite their 
numerical importance in our society, information on the health status of His- 
panic Americans has until recently been almost entirely lacking and is still 
far from adequate. With respect to diabetes, it has long been suspected based 
on clinical impression that Mexican Americans have a markedly increased prev- 
alence of this disorder. However, rigorous documentation of this excess from 
epidemiologic studies has only been forthcoming recently. It is still far 
from clear that Puerto Rican and Cuban Americans share this excess prevalence, 
and indeed it is quite possible that the excess diabetes among Hispanics is 
confined to the Mexican American subgroup. The possible significance of this 
phenomenon and its genetic implications are discussed in a subsequent section 
of this paper. 

II. Methodological considerations 

The variable criteria used to define diabetes in studies on Hispanic 
Americans are problematic. Relatively few studies have used the widely- 
accepted National Diabetes Data Group (NDDG) criteria (1). Even where the 
NDDG criteria have been used, methodological differences between studies 
exist which, as will be seen shortly, can have unexpectedly large effects 
on the reported prevalence rates. 

Not all studies have distinguished non-insulin-dependent diabetes (NIDDM) 
from insulin-dependent diabetes (IDDM). In this paper the term "diabetes" 
will be used when the two types have not been distinguished, and the term 
NIDDM will be used when this type specifically is referred to. Failure to 
distinguish between the two types of diabetes does not, however, have a very 
large effect on the reported prevalence rates in adults, since the great 
majority of diabetics identified in population-based studies of adult His- 
panic Americans are of the NIDDM type. In the San Antonio Heart Study, for 
example, only 15 of 142 adult Mexican American diabetics were insulin takers, 
but 9 of these 15 were considered on the basis of obesity (body mass index 
greater than 30.0 kgm^) and/or age of onset (greater than 40 years) to have 
NIDDM despite their having been treated with insulin (2). Thus, in this 
study, only 4 percent of adult Mexican American diabetics might possibly have 
been classified as having had IDDM. There are no data on IDDM rates in 
Hispanic American children or adolescents. 

A further problem is how to classify patients who give a history of diabetes 
but who are not hyperglycemic according to the NDDG criteria at the time they 
are studied. In this paper, such patients are considered to be diabetic only 
if they reported taking insulin or oral antidiabetic agents. This approach, 
however, could only be used when information on the use of antidiabetic medi- 
cation was reported. The rationale for this approach is that, since the new 



359 



NDDG plasma glucose criteria are set higher than former criteria, it is pos- 
sible that a number of persons who were diagnosed according to former cri- 
teria would not now be considered to have diabetes. The policy that has been 
adopted requires that all patients either meet the NDDG criteria or be known 
to be taking hypoglycemic agents at the time of the survey. 

Age- adjustment has been performed using the direct method with the U.S. 
population according to the 1970 census as the standard. 

III. Mortality 

Since diabetics most often die, not of the diabetes itself, but rather of 
its complication — for example, heart disease, kidney disease, and stroke — and 
since these diseases, rather than the diabetes, are frequently listed on the 
death certificate as the case of death, mortality statistics for diabetes 
greatly understimate the true impact of this disease on overall mortality in 
the U.S. Nevertheless, mortality statistics can be used to support the argu- 
ment that Mexican Americans suffer from excess diabetes. 

In the state of Texas, the proportionate mortality due to diabetes by 
county ranged from 8.9 deaths per 1000 total deaths to 52.0 per 1000 total 
deaths and was highly correlated with the percentage of county residents who 
had Spanish surnames (predominantly Mexican American) (3). In Bexar County, 
Texas (which contains San Antonio) , although age-adjusted mortality due to 
diabetes declined from 1970 to 1976 in both Spanish and non-Spanish surname 
residents, the rates were consistently from two to four times higher in the 
former than in the latter for both men and women (4). It should be emphasized 
that these higher diabetes mortality rates do not distinguish between excess 
disease rates per se , or merely higher case fatality rates, perhaps due to 
inferior medical care. These topics will be dealt with in subsequent sections 
of this review. 

There do not appear to be reports of diabetes mortality among Puerto 
Rican or Cuban Americans. 

IV. Prevalence of NIDDM in Mexican Americans 

Perhaps the earliest study of diabetes prevalence in Mexican Americans 
was carried out in Laredo, Texas (5). The results of this study are summar- 
ized in table 1. The age-specific prevalence rates (for total diabetics) in 
the Laredo Study are only about half of the corresponding rates in the San 
Antonio barrio (table 2). The comparison is made with the San Antonio barrio 
since the Laredo participants were all of lower socioeconomic status (SES) 
and therefore most comparable to the San Antonio bario residents. (Note: 
the age-adjusted rate in Laredo is similar to that in the San Antonio barrio, 
but this is a spurious comparison since the Laredo Study included older in- 
dividuals (45-74) years) than did the San Antonio study (25-64 years).) A 
possible explanation for the discrepancy between the San Antonio and Laredo 
rates is that only fasting plasma glucose values were available from Laredo. 
Although the NDDG fasting criteriion (>_ 140 mg/dl) were adhered to in the 
Laredo Study, subjects who failed to meet this criterion, but who might have 
met the NDDG post-glucose load criteria had glucose tolerance tests been 



360 



performed, are not included in this study, whereas they are included in the 
San Antonio study. It has recently been reported that in Mexican Americans 
the sensitivity of the fasting plasma glucose at identifying total diabetics 
is only about 59 percent (6). If the Laredo rates are inflated by dividing 
by 0.59, they approximate the rates observed in the San Antonio barrio. 
Also of note in the Laredo Study is the fact that only about 15 percent of 
the diabetics were newly diagnosed, the remainder having given a history of 
having been previously diagnosed. This proportion is quite a bit lower than 
in San Antonio (see below) and may be related to the underestimate of total 
diabetes in Laredo. It seems quite possible that the group of diabetics who 
meet only the postglucose load criteria, unidentified in the Laredo Study, 
could well contain a much larger proportion of newly diagnosed cases. 

The results of San Antonio Heart Study (7) are summarized in table 2. 
These data indicate that among San Antonio Mexican Americans , the prevalence 
of NIDDM is more than twice as high among barrio men as among the more afflu- 
ent suburban men and four times as high among barrio women as among suburban 
women. The pattern of excess NIDDM prevalence among Mexican Americans is 
made evident when these rates are compared with the same diagnostic criteria, 
the rates of NIDDM from the predominantly non-Hispanic White population 
studied in the Second National Health and Nutrition Examination Survey (HANES 
II) were 5.7 percent in men and 7.4 percent in women (2). Thus, except in 
the affluent suburbs, the rates among Mexican Americans are substantially 
higher than among non-Hispanic whites. As will be discussed shortly, the 
lower rates for Mexican Americans in the suburbs may have a genetic basis. 
Because the Mecican American population is predominantly of lower socioeco- 
nomic status (SES), the high barrio rates have the greatest public health 
relevance. 

The higher NIDDM prevalence in the barrio are partly explained by the 
greater degree of obesity of barrio Mexican Americans compared to more afflu- 
ent Mexican Americans and non-Hispanic Whites (7). However, as shown in 
table 3, obesity cannot be the sole explanation for these findings. When 
lean, average, and obese Mexican Americans are compared to non-Hispanic 
Whites closely matched for adiposity, it is seen that the former still have 
from two to three-and-a-half times higher NIDDM prevalence rates than the 
latter even at equivalent adiposity. These results have been morje fully 
described elsewhere (8). 

In San Antonio newly diagnosed cases account for 61 percent of total 
cases among men and 53 percent among women (2). In the HANES II study which 
employed identical survey procedures (i.e., NDDG) to the San Antonio study, 
49 percent of both men and women diabetics were newly discovered (2). Thus, 
it appears that the proportion of undiscovered diabetics in the population 
is approximately the same among Mexican Americans as in the general U.S. 
population. 

The prevalence of NIDDM has also been studied in Starr County, Texas (3). 
Starr County is on the U.S. -Mexican border and is one of the most impoverished 
counties in the state of Texas and, indeed, in the U.S. as a whole. The ob- 
served prevalence rates should thus be comparable to the San Antonio barrio 
rather than to the more affluent sections of San Antonio. Table 4 shows, in 



361 



addition to the age-adjusted rates for the 25 to 64 year-old population to 
facilitate comparison with the San Antonio barrio rates shown in table 2. 
Like the San Antonio Heart Study, the Starr County Study based a diagnosis 
of NIDDM on an oral glucose tolerance test using the NDDG criteria, but, 
since this study was designed primarily to identify diabetic probands for a 
family pedigree study, two pre-screen blood sugars were used to select sub- 
jects for full glucose tolerance testing. Only subjects who had a casual 
capillary whole blood glucose level* equal to or greater than 130 mg/dl 
followed by a subsequent 4-hour fasting capillary blood glucose value also 
equal to or greater than 130 mg/dl were scheduled for glucose tolerance 
testing. Hence, ascertainment of NIDDM in the Starr County Study was simi- 
lar to that of the Laredo study in that both based a diagnosis of newly 
discovered cases primarily on fasting hyperglycemia. Presumably for this 
reason, the proportion of newly diagnosed cases in Starr County is relatively 
low (20-25 percent of cases) and resembles the 15 percent proportion in 
Laredo rather than the 50 to 60 percent proportion in San Antonio. Because 
of the underascertainment of newly diagnosed cases, the age-specific and age- 
adjusted (25-64) rates in Laredo and Starr County are substantially lower 
than in the San Antonio barrio (table 2). 

V. Prevalence of diabetes in other Hispanic subgroups 

The prevalence of diabetes has also been reported from a study in Puerto 
Rico (9), the results of which are summarized in tables 5-7. This study in- 
cluded only men. Table 5 indicates that the prevalence of diabetes in Puerto 
Rico is considerably higher among urban men than among rural men. Comparing 
the rates in Puerto Rico to those recorded in San Antonio (table 2) for cor- 
responding age categories, it is apparent that the highest rates in Puerto 
Rico to those recorded in San Antonio (table 2) for corresponding age cate- 
gories, it is apparent that the highest rates in Puerto Rico (those for 
urban men) approach the lowest rates in San Antonio (those for suburban men). 
The monthly income of the Puerto Rican urban men, however, was quite low (10) 
and thus their diabetes rates should be compared with the much higher San 
Antonio barrio rates. It is difficult to judge if these prevalence differ- 
ences between Puerto Rico and the San Antonio barrio are real since the 
criteria used to diagnose diabetes in the Puerto Rico Study were quite dif- 
ferent from those used in the San Antonio Heart Study. In the Puerto Rico 
Study diabetes was diagnosed if the subject gave a history of this disease 
(cases treated by diet only were included in contrast to the procedure 
followed in San Antonio) or if a casual whole blood glucose was greater or 
equal to 140 mg/dl (equivalent to a plasma glucose of 160 mg/dl). Although 
this value is higher than the NDDG fasting cut-off of 140 mg/dl which would 
tend to lower the prevalence estimates, the specimens were casual rather than 
fasting and the Puerto Rico criteria included cases treated with diet only 
rather than only those who were receiving antidiabetic medication. Both of 
these latter procedural differences would tend to raise the prevalence 



Since capillary whole blood glucose. values are about 15 percent lower 
than plasma glucose values, a capillary whole blood glucose of 130 mg/dl 
is actually higher than the NDDG fasting criteria of 140 mg/dl. 



362 



estimates relative to the San Antonio estimates. The relative weights in 
the Puerto Rican Study averaged 1.04 for suburban men. These data suggest 
that relative leanness might in part explain the low rates among rural Puerto 
Ricans, but not among the urban dwellers. 

Table 6 shows the rates of previously and newly diagnosed diabetes sep- 
arately for both rural and urban men. Newly diagnosed cases accounted for 
42 percent of all rural cases, but only 29 percent of urban cases. 

Table 7 shows the prevalence of diabetes in Puerto Rico according to 
relative weight. As expected the prevalence rates rose progressively with 
increasing relative weight both in rural and urban men. Interestingly, at 
any given relative weight, the prevalence of diabetes was higher in urban 
than in rural men indicating that, although obesity no doubt plays a role 
in the rural-urban differences, other factors must also be involved. 

There do not appear to be any studies of diabetes prevalence in Puerto 
Ricans living in the continental U.S. Neither are there any studies as yet 
of diabetes prevalence among Cuban Americans or among other Hispanic sub- 
groups. Thus, at present there is no evidence that Hispanics other than 
Mexican Americans share the excess diabetes prevalence rates which have now 
been well-documented in Mexican Americans. The lack of data on Hispanics 
other than Mexican Americans should be in part rectified by the soon-to-be 
completed Hispanic HAT^ES study which will include data on all three major 
Hispanic subgroups in the U.S. 

VI. Factors contributing to high NIDDM prevalence in Mexican Americans 

As table 2 makes clear there is a marked effect of socioeconomic status 
(SES) on diabetes prevalence in Mexican Americans with the rates being from 
two to four times higher in the low income barrio than in the more affluent 
suburbs. Whether this effect is principally or even exclusively due to 
socioeconomic factors is unclear however, since both acculturation (11, 12) 
and genetic background (13, 14) have been shown to vary in Mexican Americans 
with changing socioeconomic status. Although upper income Mexican Americans 
tend to be more acculturated than lower income Mexican Americans, there is 
evidence that the effects of acculturation on NIDDM prevalence are indepen- 
dent of socioeconomic status. Using a series of multidimensional scales 
which evidenced excellent construct validity and internal consistency to 
measure adoption during adulthood of non-Hispanic behaviors, attitudes, and 
values, Hazuda, et. al. demonstrated that NIDDM prevalence declined with 
increasing acculturation even after adjusting for age and SES (11). Further 
adjustment for abesity suggested that the effect of acculturation could be 
attributed to changing patterns of obesity in the case of women, but was 
largely independent of obesity in men. However, obesity itself was inversely 
related to acculturation in both sexes, even after adjusting for socioecono- 
mic status (12). Thus it appears that, independent of socioeconomic status, 
aculturation may have an important effect on NIDDM prevalence in Mexican 
Americans, either through its effects on obesity in the case of women or 
through other mediating pathways in the case of men. 



363 



It seems clear that neither socioeconomic status nor acculturation effect 
NIDDM prevalence directly, but rather are proxy variables for various health 
habits which presumably have a more direct influence on the development of 
diabetes. Among the health habits which may be considered, diet and exercise 
would appear to be the most promising candidates. Apart from caloric excess 
which leads to obesity, however, there is little definitive information on 
the role of diet and exercise in the development of diabetes in Mexican 
Americans or, for that matter, in the general population. Qualitative aspects 
of the diet such as the relative proportions of fat and carbohydrate or the 
specific types of carbohydrate consumed are the subject of much speculation 
and controversey at present, but little definitive information is available. 

Socioeconomic status may also be a proxy variable for genetic background. 
It is well-established that the percent of native American ancestry varies 
inversely with socioeconomic status both in Mexico and the U.S. (13, 14). 
Since native Americans have a marked propensity to NIDDM (15) which is thought 
to be primarily on a genetic basis, it could well be that the rates of NIDDM 
in Mexican Americans are primarily attributable to their native American 
ancestry. According to this theory, the higher rates of NIDDM in low-income, 
barrio Mexican Americans compared to affluent suburban Mexican Americans 
(table 2) could be the result of the higher percentage of native American 
ancestry in the former compared to the latter. In this regard it should be 
pointed out that, because of their different historical experiences during 
the period of the colonization of the new world, Puerto Means and Cubans are 
thought to have considerably less native American ancestry than Mexican 
Americans (16). Thus, if it should turn out that these other Hispanic groups 
do not share the high rates of NIDDM found in Mexican Americans , their much 
lesser degree of Native American genetic admixture might be the explanation. 
On the other hand, it is believed that Puerto Ricans and Cubans have a higher 
degree of Black admixture than Mexican Americans (16). Blacks also have 
higher rates of NIDDM than Whites (17), but it seems unlikely that the excess 
NIDDM among Blacks equals that which has been observed in Mexican Americans. 
Unfortunately, direct comparisons of NIDDM prevalence between Blacks and 
Mexican Americans using comparable survey procedures and diagnostic criteria 
have as yet not been carried out. 

VII. Relationship of fat patterning to diabetes 

There is evidence that in addition to overall adiposity, the distribution 
of body fat may be an important determinant of various metabolic disorders. 
Only limited data are available on ethnic differences in fat patterning be- 
tween Mexican Americans and Non-Hispanic Whites. There is some evidence, 
based on subscapular and triceps skinfolds, that Mexican Americans have a 
more central distribution of fat compared to non-Hispanic Whites (18, 19). 
Recently, interest in fat patterning has shifted to lower vs. upper body 
adiposity, with the latter type considered to have a higher propensity to 
metabolic derangement. Unfortunately, there do not appear to be any data on 
ethnic differences between Mexican Americans and non-Hispanic Whites in lower 
vs. upper body adiposity, although such data are currently being collected. 
Differences in lower vs. upper body adiposity between diabetics and non- 
diabetics have, however, been reported for Mexican Americans from Starr 
County, Texas (20, 21). In this study, Mexican American diabetics had rela- 



364 



tively more upper body fat and less lower body fat than Mexican American non- 
diabetics. Since upper body fat is typically measured on the trunk and lower 
body fat on the lower extremities, it is not clear that the upper-lower body 
fat dichotomy necessarily represents a separate dimension of fat patterning 
from the central-peripheral dichotomy. Also, it is not known to what extent 
fat patterning is under genetic control, perhaps relating to native American 
admixture, or under environmental influences such as diet. 

VIII. Utilization of health services 

Evidence has recently been presented suggesting that NIDDM in Mexican 
Americans is metabolically more severe than in non-Hispanic Whites (6). This 
is illustrated by the data presented in table 8. More than twice as many 
Mexican American diabetics as non-Hispanic White diabetics had 2-hours post 
oral glucose load plasma glucose concentrations greater than 300 mg/dl. It 
is obviously of importance to determine if this less satisfactory metabolic 
control is the result of impaired access to or lower quality of medical care. 
The data presented in table 9 shed some light on this issue, although as 
discussed below, far more data on this important topic are needed. 

As in most population based surveys, the San Antonio Heart Study uncovered 
a number of newly discovered diabetics who had not been previously diagnosed. 
The proportion of such cases, however, was roughly similar in the two ethnic 
groups (table 9), suggesting that Mexican Americans are not less likely to 
have their diabetes come to medical attention. Also, the percentage of 
Mexican Americans diabetics who were under treatment with either oral agents 
or insulin was actually higher than among non-Hispanic White diabetics. This 
suggests that, rather than less adequate treatment being the cause of poor 
metabolic control, the greater hyperglycemia of Mexican American diabetics 
is a real phenomenon and has lead to more aggressive treatment by physicians. 
On the other hand, it is possible that, despite more patients having been 
prescribed antidiabetic medication, the compliance with the prescribed re- 
gimens among Mexican American diabetics is poor resulting in less satisfac- 
tory control. These findings point up the need for research on compliance 
with therapeutic regimens among Mexican American diabetics. 

Table 9 also indicates that Mexican American diabetics tend to be diag- 
nosed at an earlier age and, thus, to have a longer duration of disease for 
any given attained age. This may explain their greater degree of hyper- 
glycemia and also raises the important question of whether they have higher 
rates of diabetic complications than non-Hispanic White diabetics. This 
seems quite possible since both duration of disease and severity of hyper- 
glycemia are associated with an increased risk of various diabetic compli- 
cations. Unfortunately there is practically no information at present on 
the complication rates of Mexican American diabetics, although such data are 
currently being gathered. 

IX. Summary and recommendations 

It is clear that diabetes of the non-insulin dependent type is a major 
helath burden contributing to excess morbidity and mortality in the Mexican 
American population. There is still inadequate data, however, to say with 



365 



certainty whether this increased diabetes-related health burden extends to 
the other Hispanic subgroups in the U.S. Increased support of public health 
programs to educate the Mexican American population about diabetes and hope- 
fully to contribute to its prevention are certainly warranted. Also, efforts 
to identify undiagnosed cases and to bring them under medical surveillance 
are needed, since, as with other segments of the U.S. population, approxi- 
mately half of the Mexican American diabetics in the community are currently 
unaware of their disease. Finally expanded facilities for treating Mexican 
American diabetics are needed. Because of their unique cultural heritage, 
public health education programs aimed at prevention, and health care ser- 
vices aimed at treatment of established cases need to be tailored to the 
cultural orientation of the Mexican American population. This means, not 
only that health educational materials be made available in Spanish, the pre- 
ferred language of many Mexican Americans, but also that their content be 
sensitive to cultural nuances which can heavily influence whether such 
materials are likely to be acceptable to the population they are designed 
to serve. In addition to state and federally funded projects, volunteer 
agencies such as the American Diabetes Association can help develop these 
educational materials. On-going research on the relationship between cul- 
tural orientation and health habits and attitudes should assist in the design 
of culturally acceptable educational materials. 

Enthusiasm for expanded public health education and health services must 
be tempered by the realization that there is still much that is unknown about 
the prevention and treatment of diabetes. Although it is likely that mainte- 
nance of ideal body weight throughout life might prevent diabetes from devel- 
oping, conclusive evidence for this proposition is still lacking. If, as 
seems increasingly likely, upper body or central adiposity is an important 
determinant of the risk of future diabetes, the extent to which fat pattern- 
ing is under genetic control may limit what can be achieved through weight 
control. There is essentially no information at present on whether fat 
patterning can be influenced by potentially modifiable environmental factors. 
Overall obesity is believed to be almost entirely a consequence of caloric 
excess, irrespective of the source of calories. Whether diabetes risk or 
fat patterning can be influenced by qualitative changes in the nutrient 
composition of the diet with respect to the relative proportions of protein, 
fat, and carbohydrate or the type of carbohydrates is largely unknown at the 
present time. 

The rationale for screening programs aimed at identifying currently 
undiagnosed diabetics in the population rests on the presumption that earlier 
treatment can prevent diabetic complications, since it is these complications 
rather than the diabetes per se which are largely responsible for diabetes- 
related morbidity and mortality. Diabetic complications may be subdivided 
into two main types — macrovascular or large vessel disease such as heart 
attack and stroke; and microvascular or small vessel disease which leads to 
kidney failure and blindness as well as to other complications. Prevention 
of macrovascular complications among diabetics is but a special case of the 
more general problem of reducing the incidence of large vessel disease in 
the population at large. Here, low fat, low cholesterol diets and identify- 
ing and treating individuals with elevated blood lipids (e.g., cholesterol) 
are modalities of prevention which are supported by an impressive body of 



366 



scientific data. Since diabetics tend to have unfavorable blood lipid 
patterns relative to the general population, these preventive and therapeutic 
interventions are of particular importance for individuals with this disease. 
Because of the substantial weight of evidence suggesting that large vessel 
disease can be prevented, identification of presently undiagnosed cases of 
diabetes, and more effective treatment of diagnosed cases whether Hispanic 
or otherwise, deserves a high priority. 

Whether microvascular complications of diabetes can be prevented by 
treatment is still controversial, particularly in the case of non-insulin 
dependent diabetes, although large, multicenter trials in the U.S. (22) and 
U.K. (23) are currently in progress which should shed light on this important 
topic. 

From what has just been said it should be apparent that much research on 
fundamental topics in diabetes is still needed. It is important to establish 
whether the predispostition to diabetes found among Mexican Americans is 
shared by other Hispanic subgroups. This question should be answered in the 
case of Puerto Rican and Cuban Americans by the soon-to-be completed Hispanic 
HANES study. Studies of Hispanic children and adolescents are needed to 
assess the frequency of insulin dependent diabetes (IDDM) in this population. 
Data on this important topic are at present completely lacking. 

Further studies are needed on the customary diets of various Hispanic 
subgroups and their possible relationship to obesity, fat patterning, and 
diabetes. There are almost no data at present on micro- and macrovascular 
complication rates in Hispanic diabetics, although such data are currently 
being gathered. This is particularly important since in the San Antonio 
Heart Study, Mexican American diabetics had a longer disease duration and a 
greater severity of hyperglycemia, both of which increase the risk of dia- 
betic complications, than non-Hispanic White diabetics. These observations 
need to be confirmed in other Hispanic populations. Finially, health ser- 
vices research and research on compliance with medical regimens is needed 
in Hispanic populations to identify deficiences in either access to or 
quality of medical care and to suggest culturally valid strategies for 
correcting whatever deficiencies are uncovered. 



367 



TABLE 1 
Prevalence (percent) of diabetes in Mexican Americans in Laredo, Texas 



Age (Years) 


Previously 
Diagnosed 
Number % 


Newly 
Diagnosed 
Number 


% 


Total 


Men 












45-54 
55-64 
65-74 


3/37 
7/42 
5/30 


8.1 
16.7 
16.7 


1/37 
0/42 
2/30 


2.7 



6.7 


10.8 
16.7 
23.3 


Total, 45-74 


15/109 


13.8 


3/109 


2.8 


16.5 


Age-adjusted 
prevalence 




13.0 




2.7 


15.7 


Women 












45-54 
55-64 
65-74 


7/93 

9/70 

18/65 


7.5 
12.9 
27.7 


0/93 
3/70 
2/65 




4.3 

3.1 


7.5 
17.1 
30.8 


Total, 45-74 


34/228 


14.9 


5/228 


2.2 


17.1 


Age-adjusted 
prevalence 




14.0 




2.2 


16.1 



368 



TABLE 2 

Prevalence (percent) of noninsulin-dependent diabetes mellitus (NIDDM) 
in Mexican Americans according to socioeconomic status, the San Antonio 
Heart Study, 1979-82 









Transitional 






Barrio 




Neighborhood 
Number % 


Suburbs 


Age (Years) 


Number 


% 


Number % 


Men 












25-34 


2/50 


4.0 


1/62 


1.6 





35-44 


3/32 


9.4 


4/52 


7.8 


3.1 


45-54 


7/46 


15.2 


9/40 


22.5 


10.9 


55-64 


15/50 


30.0 


11/36 


30.6 


12.0 


Total, 25-64 


27/178 


15.2 


25/189 


13.2 


6.5 


Age-adjusted 




13.7 




14.6 


6.1 


prevalence 












Women 












25-34 


1/71 


1.4 


1/92 


1.1 


3.8 


35-44 


8/73 


11.0 


5/65 


7.7 


1.4 


45-54 


13/75 


17.3 


4/48 


8.3 


3.7 


55-64 


27/79 


34.2 


7/38 


18.4 


6.3 


Total, 25-64 


49/298 


16.4 


17/243 


7.0 


3.1 


Age-adjusted 




14.8 




8.2 


3.7 


prevalence 













369 



TABLE 3 

Prevalence (percent) of noninsulin-dependent diabetes mellitus (NIDDM) 
according to degree of adiposity in Mexican Americans and non-Hispanic 
whites, the San Antonio Heart Study, 1979-82 



Adiposity 
















Category Number 


% 


Number 


% 


Number 


% 


Number 


% 


Lean 7/87 


8.0 


1/55 


1.8 


2/83 


2.4 


0/73 





Average 9/128 


7.0 


2/54 


3.7 


9/124 


7.3 


0/77 





Obese 29/168 


17.3 


2/56 


3.6 


47/342 


13.7 


7/78 


9.0 


Mantel-Haenszel 


3, 


.59 






2. 


.30 




Prevalence ratio 


















(p<0.005) 






(p<0.025) 





370 



TABLE 4 

Prevalence (percent) of noninsulin-dependent diabetes mellitus (NIDDM) 
in Mexican Americans in Star County, Texas, 1981. 





Previously 


Newly 








Diagnosed 
Number 


% 


Diagnosed 






Age (Years) 


Number 


% 


Total 


Men 












15-24 


0/211 





0/211 








25-34 


3/115 


2.6 


0/115 





2.6 


35-44 


3/92 


3.3 


0/92 





3.3 


45-44 


7/95 


7.4 


5/95 


5.3 


12.7 


55-64 


11/85 


12.9 


3/85 


3.5 


16.4 


64-74 


8/60 


13.3 


2/60 


3.3 


16.6 


75+ 


4/34 


11.8 


2/34 


5.8 


17.6 


Total, 15-75 


36/692 


5.2 


12/692 


1.6 


7.9 


Age-adjusted 












prevalence 












(15-75 yrs) 




5.6 




1.9 


7.5 


Age-adjusted 












prevalence 












(25-64 yrs) 




6.2 




2.1 


8.3 


Women 












15-24 


1/285 


0.4 


0/285 





0.4 


25-34 


1/254 


0.4 


0/254 





0.4 


35-44 


8/210 


3.8 


4/210 


1.9 


5.7 


45-54 


17/204 


8.3 


5/204 


2.5 


10.8 


55-64 


26/142 


18.3 


1/142 


0.7 


19.0 


65-74 


10/94 


10.6 


6/94 


6.4 


17.0 


75+ 


3/50 


6.0 


1/50 


2.0 


8.0 




66/1,239 


5.3 


17/1,239 


1.4 


6.7 


Total, 15-75 












Age-adjusted 












prevalence 












(15-75 yrs) 




5.7 




1.4 


7.1 


Age-adjusted 












prevalence 












(25-64 yrs) 




7.0 




1.3 


8.3 



371 



TABLE 5 

Prevalence (percent) of diabetes in Puerto Rican men ages 45 to 64, Puerto 
Rico Heart Health Program, 1965. 





Rural Men 




Urban 


Men 




Age (Years) 


Numbe r 


% 


Number 




% 


45-49 


16/552 


2.9 


113/1,683 




6.7 


50-54 


24/735 


3.3 


174/1,935 




9.0 


55-59 


22/684 


3.2 


134/1,427 




9.4 


60-64 


31/596 


5.2 


135/1,145 




11.7 


Total, 45-64 


93/3,567 


3.6 


555/6,190 




9.0 


Age-adjusted 












prevalence 




3.5 






9.0 



TABLE 6 

Prevalence (percent) of previously and newly diagnosed diabetes in Puerto 
Rican men ages 45 to 64, Puerto Rica Heart Health Program, 1965. 



Rural Men 



Urban Men 



Previously diagnosed 



Euglycemic 
Hyperglycemic 


1.3 
0.8 


Newly diagnosed 


1.5 


Total 


3.6 



3.6 
2.8 

2.6 

9.0 



372 



TABLE 7 

Prevalence (percent) of diabetes according to relative weight in Puerto Rican 
men ages A5 to 64, Puerto Rico Heart Health Program, 1965. 





Rural Men 


Urban 


Men 


Relative Weight 


Number 


% 


Number 


% 


Age 45-54 










<100 


8/545 


1.5 


21/604 


3.5 


100-109 


2/303 


0.7 


29/593 


4.9 


110-125 


13/302 


4.3 


121/1,374 


8.8 


>125 


17/135 


12.6 


115/1,042 


11.0 


Age 55-64 










<100 


10/630 


K6 


28/592 


4.7 


100-109 


7/279 


2.5 


40/448 


8.9 


110-125 


23/254 


9.1 


107/870 


12.3 


>125 


13/115 


11.3 


93/659 


14.1 



TABLE 8 

Severity of hyperglycemia in Mexican Americans and non-Hispanic Whites 
with NIDDM, the San Antonio Heart Study, 1979-82. 



Plasma glucose concentration 
2-hours post oral glucose load 



less than 
300 mg/dl 



greater than 
300 mg/dl 



Mexican American diabetics 
non-Hispanic White diabetics 



50.9% 
76.6% 



49.1% 
23.4% 



373 



TABLE 9 

Distribution of NIDDM in Mexican Americans and non-Hispanic Whites according 
to diagnostic and treatment status, the San Antonio Heart Study, 1979-82. 



Mexican 
American 
Numbe r 



non-Hispanic 
White 



Number 



% 



Newly diagnosed 

Previously diagnosed 
diet treatment only 
treatment with oral agents 
treatment with insulin 

mean age at diagnosis 
mean duration of diabetes 



74 



58.3 



30 



17 


13. 


.4 


27 


21, 


.3 


9 


7, 


.1 


43 


yrs 




9.4 


yrs 





61.2 



2 


24.5 


4 


8.2 


3 


6.1 


40 


yrs 


7.5 


yrs 



374 



a U. S. GOVERNMENT PRINTINC OFFICE : 1986 491-313/44709